7233 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


7233 


SURGICAL 
THERAPEUTICS 


BY 

EMORY  LANPHEAR,  M.  D.,  Ph.  D.,  LL.  D. 

ST.  LOUIS,  MO. 

Professor  of  Surgery,  Hippocratean  College  of  Medicine;  Formerly  Professor 

of  Operative  Surgery  in  the  Kansas  City  Medical  College  and 

Professor  of  Surgery  in  the   St.  Louis    College   of 

Physicians  and  Surgeons.     Chief  Surgeon 

to  the  Woman's  Hospital  of  the 

State    of    Missouri 


CHICAGO 

THE  CLINIC  PUBLISHING  COMPANY 
1907 


Copyrighted 

THE  CLINIC  PUBLISHING  COMPANY 
1907 


Library 
ItfB 

300 


FOREWORD 

There  are  hundreds  of  books  telling  how  to 
operate — not  one  describing  the  proper  management 
of  the  patient  without  operation.  Almost  as  many 
give  careful  directions  as  to  when  operations  should 
be  done — but  with  only  trifling  mention  of  the  prop- 
er preparation  of  the  patient  for  the  operative  work, 
of  the  best  way  to  make  him  comfortable  after  oper- 
ation, or  of  the  right  management  of  the  wound  to 
get  ideal  results.  In  other  words:  there  is  no  work 
on  the  non-operative  treatment  of  surgical  conditions. 
The  object  of  this  little  book  is  to  give  some  of  the 
important  points  neglected  by  or  omitted  from  the 
^xmore  elaborate  works  on  surgery. 

It  is  based  chiefly  upon  personal  experience,  es- 

;  pecially  in  the  management  of  cases  in  the  country 
\ 
[nand  in  private  houses  in  the  city,  though  of  course 

many  of  the  suggestions  are  for  especial  use  in  hos- 
pital practice.  It  is  not  intended  to  be  regarded  as 

^a  complete  treatise  on  "  Surgical  Therapeutics,"  in- 
deed, it  might  perhaps  more  properly  be  called 
"Practical  Suggestions  for  the  Management  of  Surg- 
ical Cases."  If  it  meets  the  approval  of  the  vast 

;  number  of  doctors  who  try  to  manage  their  own 
surgical  cases,  it  will  be  followed  later  by  a  more 

,  elaborate,  complete  work  covering  the  entire  field  of 
v  non-operative  surgery. 

624351 


If  the  reader  who  is  interested  in  this  line  of  work 
will  deliberately  read  this  little  book  "straight 
through  "  from  beginning  to  end,  and  then  later  re- 
fer to  any  special  section  he  may  desire  to,  he  will,  I 
am  sure,  obtain  better  results  than  if  he  attempt  to 
merely  read  here  and  there  as  his  fancy  may  dictate. 

EMORY  LANPHEAR 

ST.  Louis,  MISSOURI. 


ABDOMINAL  SECTION 

Abdominal  Tumors. — As  a  rule,  operable  tumors 
should  be  removed  at  the  earliest  possible  moment  after  their 
existence  is  detected.  Those  which  are  usually  removable 
without  much  danger  are:  (i)  tumors  of  the  gall-bladder, 

(2)  tumors  of  the  intestine,  (3)  tumors  of  the  omentum, 
(4)  tumors  of  the  uterus,  (5)  tumors  of  the  ovary.     Those 
which  may  sometimes  be  removed,  with  a  considerable 
degree  of  danger,are:  (i)  tumors  of  the  stomach,  (2)  tumors 
of  the  bladder,   (3)   tumors  of  the  broad  ligament,   (4) 
tumors  of  the  kidney.    Those  which  are  rarely  removable 
are:  (i)  tumors  of  the  liver,  (2)  tumors  of  the  pancreas, 

(3)  tumors  of  the  spleen.    When  it  is  certain  these  growths 
are  of  malignant  character  the  probabilities  of  cure  even 
by  early  excision  are  not  good.     Nevertheless,  very  much 
may  often  be  done  by  purely  palliative  operations  (such 
as  gastroenterostomy,  artificial  anus  and  the  like)  which 
will  prolong  life  and  make  the  sufferer  far  more  nearly  com- 
fortable.   When  any  (even  inoperable)  tumor  undergoes 
suppurative   inflammation  the  pus  should  be  evacuated 
by  two  operations:  the  first  to  secure  protective  adhesions, 
the  second  to  drain  the  abdomen. 

Adhesions:  Prevention  of. — In  abdominal  surgery 
one  of  the  most  important  things  is  to  leave  the  belly  in 
such  shape  that  adhesions  will  not  form.  To  this  end 
much  time  may  profitably  be  spent  (except  in  cases  of 
emergency  where  immediate  closure  is  imperative)  in  doing 
work  to  prevent  any  raw  surface  being  left  exposed;  for, 
if  it  be,  an  intestine  or  other  strucure  is  almost  cer- 
tain to  adhere  and  cause  future  suffering — especially  in 
nervous,  hysterical  or  neurasthenic  persons. 


2  SURGICAL  THERAPEUTICS 

The  best  way  is  to  cover  thoroughly  every  denuded  sur- 
face with  peritoneum;  but  if  this  is  impossible,  the  omen- 
turn  is  to  be  brought  to  the  bare  place  and  sutured  over 
it,  if  possible,  in  such  way  that  there  is  no  traction  on 
the  omentum.  In  some  cases,  where  neither  can  be  done, 
it  is  good  practice  to  rub  the  raw  surface  thoroughly  with 
sterilized  olive  oil.  Silver-foil  has  been  suggested,  but 
it  cannot  be  employed  satisfactorily  and  should  not  be 
tried  (though  it  may  be  used  in  the  brain).  A  20-per- 
cent solution  of  gelatin  with  i -percent  formalin  has  also 
been  recommended,  hut  is  worse  than  useless.  Cargile 
membrane  has  also  proven  of  little  value  in  my  own 
experience. 

On  the  whole  it  may  be  said  that  there  is  no  effectual 
way  of  preventing  adhesions  except  carefully  to  cover 
every  torn  or  cut  surface  with  peritoneum  or  omentum. 
Even  rough  handling  of  intestines  with  gauze  or  towel 
will  produce  enough  erosion  of  the  serosa  to  cause  adhesions; 
hence  the  necessity  of  dealing  as  gently  as  possible  with 
the  peritoneum  everywhere. 

Calomel  in  Abdominal  Surgery. — Calomel  is  a  fa- 
vorite with  many  surgeons  who  do  much  abdominal  work 
— not  in  the  large  doses  of  our  forefathers,  but  in  tablets 
or  granules  containing  a  half  centigram  (approximately  1-12 
grain)  in  sugar  of  milk.  These  are  given  beginning  on 
the  second  day  following  operation,  at  which  time  the 
tongue  is  often  dry,  the  abdomen  slightly  tympanitic  and 
the  stomach  a  little  disturbed,  especially  if  too  much  water 
has  been  permitted.  If  to  such  a  patient  one  tablet  be 
given  every  hour  (one  every  half-hour  if  early  catharsis 
seems  desirable)  until  ten  are  taken,  there  will  be  a  marked 
change  for  the  better  in  patients  not  too  profoundly  septic; 
the  tongue  will  become  moist,  gas  will  begin  to  pass,  the 
nausea  will  disappear,  thirst  will  diminish  and,  if  at  the 
end  of  the  course  a  mild  saline  laxative  be  given,  free  bowel- 


ABDOMINAL  SECTION  3 

movement  will  speedily  follow — after  which  the  period  of 
acute  danger  will  have  been  passed. 

Codeine  in  Abdominal  Surgery. — One  of  the  most 
useful  drugs  in  abdominal  work  is  codeine  phosphate. 
The  phosphate  is  preferable  to  the  more  common  sulphate 
on  account  of  its  free  solubility — of  particular  importance 
for  hypodermic  medication.  It  is  the  best  of  all  prepara- 
tions of  opium  because  (i)  it  does  not  check  secretions  like 
morphine,  (2)  a  codeine  habit  is  not  easily  formed  and 
(3)  it  does  not  produce  the  distressing  secondary  nausea 
of  other  opiates.  After  an  abdominal  section,  when  the 
patient  complains  bitterly  of  pain  and  general  discomfort, 
fifty  centigrams  (from  a  half  grain  to  a  grain)  may  be  in- 
jected and  repeated  in  an  hour  if  necessary.  It  being 
mildly  anodyne  and  hypnotic  the  patient  generally  feels 
sufficiently  comfortable  after  two  doses  not  to  require  a 
third  for  some  hours,  when  the  two  doses  one  hour  apart 
may  be  repeated.  Old  tablets  may  not  dissolve  readily; 
if  so,  add  a  little  phosphoric  acid. 

Elaterin  in  Abdominal  Surgery. — After  certain  oper- 
ations it  becomes  necessary  to  secure  very  early  bowel- 
movement;  calomel  is  too  slow  and  salines  are  apt  to  pro- 
voke vomiting.  Here  elaterin  (the  glucoside  active  prin- 
ciple of  the  elaterium  of  the  shops)  can  be  employed  with 
the  greatest  satisfaction.  It  should  be  given  in  granules, 
each  containing  one  milligram  (i-67th  of  a  grain)  one  every 
hour  until  five  or  six  have  been  taken  or  copious  move- 
ments have  been  secured.  If  emesis  results,  the  elaterin 
should  be  temporarily  discontinued  and  one  milligram  of 
salicylate  of  eserine  given  hypodermically  every  hour,  four 
times;  by  this  the  peristaltic  wave  will  be  reversed  and  the 
fecal  current  started  downward;  then  the  elaterin  may  be 
resumed.  When  black- vomit  begins  after  operation,  this 
is  by  far  the  most  effective;  especially  when  supplemented 
by  washing  out  the  stomach. 


4  SURGICAL  THERAPEUTICS 

Enema  after  Abdominal  Section. — After  abdominal 
section  cathartics  can  not  be  given  early  by  the  mouth  on 
account  of  nausea.  In  such  cases  when  it  is  desirable  to 
secure  bowel-movement  the  following  enema  thrown  high 
into  the  rectum,  may  be  given: 

Epsom  salt,  5o-percent  solution ozs.  2 

Oil  of  turpentine ozs.  2 

Glycerin ozs.  2 

Water ozs.  6 

The  injection  is  to  be  held  in  the  bowel  as  long  as 
possible  by  the  patient.  It  is  well  to  anoint  the  inner 
thighs  and  buttocks  in  order  to  prevent  irritation  of  the 
parts  should  they  come  in  contact  with  the  turpentine  by 
mischance. 

Opium  after  Abdominal  Section. — The  only  cases 
in  which  opium  (or  morphine)  is  indicated  after  abdom- 
inal operations  are  those  in  which  the  intestine  has  been 
injured,  cut  into,  torn  into,  or  anastomosis  made.  Then 
peristalsis  is  undesirable,  as  any  movement  of  the  bowels 
tends  to  prevent  the  formation  of  early,  firm  adhesions 
on  which  the  life  of  the  patient  depends.  Opium  above 
all  other  drugs  checks  peristalsis;  hence  full  doses  of  sul- 
phate of  morphine  may  be  injected  hypodermically  every 
four  to  six  hours  during  the  first  forty-eight  hours  fol- 
lowing such  an  operation;  but  no  further  use  would  be 
beneficial,  as  adhesions  have  been  formed  by  that  time, 
if  ever.  In  all  other  section-work,  if  an  opiate  seems  un- 
avoidable, grain-doses  (six  centigrams)  of  phosphate  of 
codeine  may  be  injected  hypodermically  every  three  or 
four  hours  as  required;  morphine  alone,  never. 

Peritonitis  Following  Operation. — Peritonitis  is 
a  localized  trouble,  and  is  essentially  life-saving  when  not 
too  extensive  or  severe,  the  adhesions  formed  thereby 
serving  to  limit  the  spread  of  suppuration.  That  which 
is  commonly  called  "general  peritonitis,"  with  its 


ABDOMINAL  SECTION  5 

vomiting,  collapse  and  death,  is  acute  sepsis  of  the 
most  serious  type. 

But  sometimes  the  peritoneal  surfaces  do  not  aggluti- 
nate around  a  point  of  infection  (as  a  typhoid  perforation, 
a  gangrenous  appendicitis  or  a  pus-tube)  and  the  general 
peritoneal  cavity  becomes  a  huge  absorption-sac,  so  that 
the  system  is  speedily  overwhelmed  and  death  from  poison- 
ing of  the  heart-muscle  (with  true  "  heart  -failure")  quickly 
supervenes — unless  the  surgeon  has  the  courage  and  the 
skill  to  act  promptly  and  properly. 

These  are  the  cases  formerly  treated  by  Sir  Andrew 
Clark  with  calomel,  followed  by  opium — the  idea  being  to 
paralyze  the  bowel  so  that  protective  adhesions  may  form — 
and  still  advocated  by  some  who  are  not  familiar  with  intra- 
abdominal  pathology.  With  this  line  of  treatment  it  is 
common  to  order  hop  poultices,  turpentine  stupes,  Crede's 
ointment,  cataplasma  kaolini,  ice-bags,  etc.,  all  of  which 
tend  to  comfort  the  patient's  mind  and  afford  relief  to 
the  anxious  friends  who  want  to  "do  something,"  but  they 
have  but  little  if  any  effect  upon  the  pathology  save  to 
hasten  spontaneous  rupture  of  an  abscess  about  ready 
to  break  through  the  skin. 

The  truth  is,  there  are  but  two  curative  measures  pos- 
sible :  to  remove  (or  render  less  dangerous)  a  source  of  local 
infection,  and  to  rid  the  peritoneum  of  the  infective  material 
already  poured  out  into  it. 

It  is  true  that  in  a  large  proportion  of  cases  the  peri- 
toneum affected  is  of  but  trifling  extent  (as  around  the 
appendix,  or  in  the  pelvis  where  absorption  is  excessively 
slow,  the  stomata  being  very  few  as  compared  with  the 
dangerous  areas  like  the  diaphragmatic  peritoneum)  and 
adhesions  prevent  the  dissemination  of  the  poison.  But 
when  symptoms  indicate  that  the  protective  barrier  is  not 
being  thrown  out  there  must  not  be  any  delay.  This  rule 
is  applicable  alike  to  appendicitis,  to  salpingitis,  to  chole- 


6  SURGICAL  THERAPEUTICS 

cystitis  and  to  intestinal  obstructions;  it  is  imperative  in 
all  penetrating  wounds  of  the  abdomen,  in  ruptured  gall- 
bladder, in  perforation  of  gastric  or  duodenal  ulcers,  in 
leakage  of  pyosalpinx,  in  volvulus  and  even  in  the  giving 
way  of  the  intestine  in  typhoid  fever — practically  all  cer- 
tain to  end  in  death  unless  quickly  and  skilfully  remedied. 

When  there  must  be  some  delay  in  operating,  the  pa- 
tient should  be  kept  in  the  Fowler  position:  the  head  of 
the  bed  raised  upon  a  chair  so  that  all  of  the  infected  fluid 
in  the  belly  will  run  into  the  pelvis  where  absorption  is 
slow. 

Now  all  this  applies  with  extra  force  to  postoperative 
peritonitis.  Here  the  surgeon  expects  serous  surfaces  to 
adhere,  in  order  to  cover  the  line  of  incision  and  the  wounded 
surfaces.  If  the  work  has  been  performed  aseptically  a 
non-inflammatory  adhesion  will  follow,  completely  burying 
all  exposed  and  injured  surfaces;  and  results  will  usually 
be  satisfactory.  But  if  (i)  pyogenic  bacteria  have  been 
carried  in  by  dirty  fingers  or  non-sterile  gauze  or  instru- 
ments, or  if  (2)  some  pathologic  conditions  have  been  found 
which  cannot  be  entirely  excised  without  soiling  of  peri- 
toneum, or  if  (3)  some  viscus  has  been  so  injured  that  it 
may  discharge  infective  contents  into  the  peritoneum,  a 
general  infection  of  the  peritoneum  may  occur,  with -speedy 
death. 

Now,  following  the  abdominal  operations  there  are  cer- 
tain disturbances  which  are  practically  normal:  slight  rise 
of  temperature,  vomiting,  pain,  etc.,  yet  which  if  continued 
clearly  indicate  serious  peritoneal  infection;  so  the  question 
of  greatest  import  is:  What  are  the  signs  pointing  unequivo- 
cally to  peritoneal  infection? 

The  first  and  foremost  symptom  is  vomiting.  When 
the  bile-tinged  water  changes  to  a  greenish-brown  and  when 
the  straining  of  anesthesia -ernes  is  is  succeeded  by  practically 
effortless  vomiting  (not  immediately  and  permanently  re- 


ABDOMINAL  SECTION  7 

lieved  by  once  washing  out  the  stomach)  there  can  be  no 
doubt  of  serious  sepsis,  and  delay  in  proper  treatment 
means  a  fatal  termination. 

Accompanying  this  is  persistent  refusal  of  the  bowels 
to  move,  not  even  gas  escaping.  With  this  absence  of 
peristalsis  comes  distension  of  the  abdomen — tympanites. 
If  under  the  most  vigorous  purgatives,  supplemented  by 
high  enema ta,  no  bowel-movement  can  be  induced  the 
experienced  operator  does  not  hesitate  to  open  the  belly 
to  correct  the  disease  if  possible.  He  who  waits  until  ster- 
coraceous  vomiting  appears  never  saves  a  life. 

The  temperature  behavior  is  peculiar.  There  is  rarely 
much  fever;  the  very  worst  cases  have  a  subnormal  record. 
But  if  there  be  a  fever  above  ioi°F.,  it  is  corroborative 
(merely)  of  the  other  signs. 

If  now,  to  the  signs  of  persistent  vomiting,  tympanites 
and  paresis  of  gut,  there  be  added  a  knowledge  that  there 
is  strong  probability  of  something  wrong  inside,  as  a  fail- 
ure to  provide  drainage  in  a  doubtful  case,  the  likelihood 
of  a  leakage  from  an  improperly  closed  opening  in  intestine 
or  gall-bladder,  too  free  oozing  into  the  pelvis  from  torn 
adhesions,  uncertainty  as  to  perfect  aseptic  technic  during 
operation,  etc.,  the  surgeon  ought  scarcely  to  hesitate  about 
the  justifiability  to  reopen  and  clean  up.  Yet  even  the 
most  experienced  surgeons  do  hesitate  in  this  matter,  often 
"hoping  against  hope"  until  it  is  too  late. 

As  soon  as  it  has  been  decided  that  reopening  the  abdo- 
men is  necessary,  an  injection  of  one  tablet  of  the  hyoscine- 
morphine-cactin  anesthetic  is  to  be  made  (hyoscine,  gr. 
i-ioo;  morphine,  gr.  1-4;  and  cactin,  gr.  1-67);  by  the 
time  instruments  and  hands  are  sterilized  the  patient  will 
be  so  sleepy  that  but  a  few  drops  of  chloroform  will  be 
needed — a  matter  of  great  importance  because  the  patient 
is  already  so  weak  and  nauseated;  besides  it  induces  a  condi- 
tion of  tranquillity  after  the  work  is  done.  In  case  the 


8  SURGICAL  THERAPEUTICS 

patient  is  too  weak  for  an  inhalent  anesthetic  the  work 
may  be  done  with  one  hypodermic  injection,  plus  cocaine 
anesthesia  locally;  but  it  is  best,  when  possible,  to  have 
the  patient  oblivious  to  what  is  being  done. 

Invariably  before  beginning  the  operative  work  the 
stomach  must  be  washed  out  with  salt-solution. 

The  belly  should  be  opened  with  two  objects  well 
denned  in  the  mind  of  the  surgeon:  (i)  To  clean  out  the 
abdominal  cavity  as  speedily  and  perfectly  as  possible  and 
(2)  to  locate  quickly  and  correct  the  source  of  infection; 
or  if  not  possible  of  correction,  to  afford  perfect 
drainage. 

i.  To  attain  the  first,  one  must  be  guided  by  the  con- 
ditions present  as  to  method:  (a)  When  the  infection  is 
presumed  to  be  general,  and  dependent  upon  faulty  technic 
(dirty  hands  or  instruments  or  sponges)  probably  the  best 
procedure  is  to  open  widely  the  wound  and  pour  in  large 
quantities  of  normal  salt  solution,  temperature  of  102°- 
io5°F.,  inserting  a  hand  first  into  the  pelvis  and  separating 
the  coils  of  intestine  so  that  irrigation  may  reach  all  parts 
of  the  lower  abdomen;  when  that  has  been  effectively 
flushed  the  hand  and  the  solution  are  to  be  turned  toward 
the  diaphragm  and  the  upper  part  of  the  abdominal  cavity 
washed  out  with  even  more  care  than  that  bestowed  upon 
the  lower  tracts  where  absorption  is  not  so  active.  From 
two  to  ten  gallons  of  salt  solution  may  thus  be  used — con- 
tinuing the  stream  until  all  flocculi  or  tinged  serum  seem 
to  be  removed. 

In  this  process  of  irrigation  a  large  rubber  tube  with 
a  funnel  is  the  instrument  of  choice,  as  the  tube  can  be 
carried  to  the  depths  and  the  infective  material  thus  be 
thrown  out  much  more  easily  than  if  a  pitcher  be  used 
and  the  fluid  merely  poured  in  and  allowed  to  run  out. 

(b)  The  same  method  is  best  when  there  is  intestinal 
perforation  with  large  outpouring  of  fecal  matter. 


ABDOMINAL  SECTION  9 

(c)  When  the  trouble  is  due  to  accumulation  of  in- 
fected serum  in  the  pelvis  (as  after  removal  of  a  uterine 
fibroid,  without  drainage)  the  pelvis  only  need  be  irrigated, 
and  it  is  best  to  have  the  patient  in  the  Fowler  position 
during  the  cleansing  so  that  the  infectious  material  be  not 
spread  over  the  non-infected  peritoneum  by  flooding  of  the 
upper  abdomen.     In  such  cases  it  is  best  to  thoroughly 
dry  the  pelvis  and  then  pack  loosely  with  gauze  (left  pro- 
truding through   the  wound)   pulling  the  omentum  well 
into  the  pelvis  and  tucking  it  in  around  the  gauze,  between 
it  and  the  brim  of  the  pelvis. 

(d)  When  the  infection  is  presumed  to  be  merely  a 
localized  one,  as  at  the  site  of  pyosalpinx  just  removed  or 
a  :  ecently  excised  appendix,  it  is  better  merely  to  wipe 
the  peritoneum  dry,  especially  the  pelvis   and  the  spaces 
just  below  each  kidney,  where  infected  serum  is  prone  to 
accumulate,  and  insert  drainage. 

2.  When  the  source  of  infection  is  known  to  be  a  local 
one,  as  (a)  a  leak  from  the  stump  of  an  appendix,  (b)  a 
perforation  of  gut  (quite  likely  to  occur  when  extensive 
adhesions  between  coils  of  intestines  have  been  broken  up), 
(c)  failure  to  form  adhesions  around  a  drained  gall-bladder 
or  other  infected  part,  (d)  oozing  from  torn  adhesions, 
(e)  contamination  by  urine  through  a  torn  ureter  or 
around  a  ligature  or  suture  passed  into  the  bladder  by 
mistake,  or  any  other  cause,  the  first  duty  of  the  surgeon 
is  to  seek  this  local  trouble  and  correct  it,  if  possible;  if 
not,  then  to  irrigate  or  clean  by  wiping,  and  drain. 

In  the  process  of  wiping,  great  care  must  be  exercised 
not  to  do  harm  to  the  peritoneum.  Soft  pads  of  gauze 
should  be  used,  wrung  out  of  the  hot,  normal  salt  solution 
already  at  hand  for  irrigation,  if  indicated.  Pus  and  flakes 
of  fibrin  adherent  to  the  intestine  must  be  carefully  re- 
moved, but  not  enough  force  should  ever  be  employed  to 
make  the  musculosa  bleed,  for  the  serosa  often  has  to  be 


10  SURGICAL  THERAPEUTICS 

removed  with  the  fibrin  if  an  attempt  be  made  to  get  all; 
it  is  best  to  take  away  only  that  which  comes  away  easily. 
As  each  loop  of  intestine  is  cleaned  it  should  be  slipped 
back  into  the  belly  and  held  there,  gently,  by  means  of 
a  hot; .moist  towel  or  large  pads  of  gauze. 

In  rare  instances  when  the  source  of  infection  is  in 
the  pelvis  it  is  advisable  to  clean  the  abdomen  (and  espe- 
cially the  pelvis)  as  thoroughly  as  possible  and  then  put  the 
patient  in  the  Trendelenburg  position  so  that  all  of  the 
intestines  are  thrown  well  out  of  the  pelvis,  then  again  clean 
the  pelvis — particularly  the  depths  of  the  cul-de-sac  of 
Douglas  (which  cannot  well  be  cleaned  with  the  patient 
lying  flat  upon  the  table)  and  then  quickly  pack  the  entire 
pelvis  with  gauze,  not  very  tightly,  and  hastily  return  the 
patient  to  bed. 

As  a  rule  no  attempt  should  be  made  to  suture  the 
incision;  one  or  two  through-and-through  stitches  may  be 
introduced  if  the  cut  is  unusually  long;  but  in  general  the 
dressings  supported  by  two  or  three  adhesive  straps  and  a 
binder  will  keep  the  sides  of  the  wound  in  close  contact  with 
the  gauze.  Care  must  be  taken  not  to  have  the  retaining 
straps  or  binder  so  placed  as  to  interfere  with  drainage, 
for  in  free  discharge  of  fluid  lies  the  hope  of  saving  the 
patient. 

As  soon  as  the  patient  has  been  returned  to  bed  the  most 
vigorous  measures  must  be  instituted  to  tide  him  through 
the  next  few  hours — until  protective  adhesions  can  be 
formed.  These  are: 

1.  Hypodermoclysis.     A  quart  of  normal  salt-solution 
should  be  thrown  into  the  cellular  tissue  below  the  breasts. 
It  may  be  repeated  in  four  or  six  hours  if  indicated,  the 
buttocks  being  selected  for  the  second  injection. 

2.  Application  of  heat.    Hot  water  bags,  or  bottles, 
must  be  applied  to  the  extremities  just  as  in  the  treatment 
of  shock. 


ABDOMINAL  SECTION  1-1 

3.  Hypodermic  stimulation.     If  the  pulse  is  impercep- 
tible, camphorated  oil  should  be  injected.     In  a  few  min- 
utes i-ioo  grain  of  glonoin  may  be  thrown  under  the  skin. 
And  in  a  half  hour  i-ioo  grain  of  sulphate  of  strychnine 
may  follow.     This  may  be  repeated  in  an  hour  if  the  pulse 
flags  again. 

4.  Enemas.     Six  or  eight  ounces  of  black  coffee  with 
one  ounce  of  whisky  may  be  thrown  into  the  rectum  as 
soon  as  possible  after  operation.     As  soon  as  it  is  seen  that 
the  patient  will  not  die  from  shock,  one  milligram  (gr.  1-60) 
of  salicylate  of  eserine  should  be  injected  hypodermically, 
every  hour  until  four  doses  are  given;  this  starts  the  peri- 
staltic  wave   downward  and   acts    as    a   decided   nerve- 
sedative. 

Then  one  milligram  of  elaterin  (not  elaterium)  may  be 
given  by  mouth,  with  a  little  sup  of  water,  every  hour 
until  six  doses  have  been  taken.  If  retained,  this  will 
usually  cause  free,  watery  discharges  from  the  bowels. 

6.  Internal  Medicines.  As  soon  as  the  stomach  will 
retain  anything  of  bulk,  i.  e.,  about  the  time  of  the  last 
dose  of  elaterin,  stimulants  may  be  begun,  teaspoonful  doses 
of  iced  champagne  every  fifteen  or  twenty  minutes  being 
the  best.  If  the  patient  go  to  sleep  he  should  not  be  dis- 
turbed for  this. 

If  vomiting  occur  the  stomach  must  once  more  be 
washed  out.  One  lavage  will  often  afford  perfect  relief 
from  the  distressing  nausea  and  the  profound  depression. 
Indeed  it  often  seems  to  do  more  toward  securing  a  favor- 
able ending  than  all  the  other  measures  together. 

Phlebitis. — Phlebitis  following  abdominal  section  is 
quite  common.  Strange  to  say,  it  occurs  more  often  in  the 
left  leg,  even  after  appendicitis  operations.  It  is  a  complica- 
tion which  always  causes  the  surgeon  the  gravest  anxiety. 
It  is  attended  by  pain,  tenderness,  possibly  tympany,  and 
usually  some  rigidity,  associated  with  fever  and  leuco- 


12  SURGICAL  THERAPEUTICS 

cytosis.  It  can  only  be  diagnosed  by  excluding  other 
symptoms  and  by  demonstrating  some  peripherally  throm- 
bosed  vessel.  Thrombosis  of  the  long  saphenous  vein, 
fortunately  not  frequent,  but  occasionally  encountered 
after  the  cleanest  kind  of  abdominal  work,  is  best  perhaps 
prevented  by  changing  the  patient's  position  and  by  gentle 
massage  of  the  extremities,  as  advised  by  Martin. 

Post-Operative  Obstruction  of  the  Bowels. — 
Following  any  operation  within  the  abdomen  there  is 
more  or  less  interference  with  peristalsis.  In  some  cases, 
such  as  gastroenterostomy,  intestinal  resection  or  anas- 
tomosis, and  wounds  of  the  gut,  inactivity  is  favorable 
since  it  permits  of  the  formation  of  protective  adhesions; 
but  in  ordinary  abdominal  sections  the  conscientious 
surgeon  feels  anxiety  until  after  the  bowels  have  moved 
freely.  For  of  all  postoperative  complications  ileus 
paralyticus  is  most  feared,  excepting  acute  sepsis;  and 
indeed  many  cases  of  socalled  "obstruction"  after  opera- 
tion are  but  acute  sepsis,  the  non-movement  of  bowels 
being  merely  one  of  the  symptoms.  But  even  when 
septic  or  agglutinative  peritonitis  is  not  severe  intestinal 
inertia  may  result  in  kinking  of  the  gut,  with  adhesions 
and  fatal  obstruction,  particularly  when  there  has  been 
much  rough  handling  of  intestines. 

Obstruction  of  the  bowel  soon  after  operation  may 
depend  upon: 

1.  Paralysis  of  bowel,  either  septic  or  spontaneous; 

2.  Volvulus; 

3.  Internal  hernia; 

4.  Thrombosis  of  the  intestinal  vessels; 

5.  Surgical  interference  with  peristalsis; 

6.  Preoperative  conditions. 

A  paralytic  condition  of  the  bowels,  or  at  least  an 
inability  to  move  properly,  is  one  of  the  first  symptoms 
of  socalled  "septic  peritonitis,"  really  acute  sepsis;  and 


ABDOMINAL  SECTION  13 

associated  with  the  failure  to  pass  gas  or  feces  is  vomit- 
ing, followed  after  a  few  hours  by  "reversed  peristalsis," 
the  expulsion  of  bile-tinged  water  and  mucus  from  the 
stomach  changing  to  stercoraceous  vomiting.  This  is 
the  "black  vomit"  of  acute  sepsis  so  greatly  feared.  It 
is  to  prevent  this  failure  of  proper  bowel-movement  that 
the  experienced  surgeon  withholds  opiates  and  gives  early 
cathartics.  Indeed  some  operators  give  a  large  dose  of 
castor  oil  or  a  saline  laxative  two  hours  before  opera- 
tion: a  rather  commendable  practice  if  it  be  known  posi- 
tively that  operation  upon  the  intestine  will  not  be  neces- 
sary. And  others  begin  the  administration  of  half  a 
centigram  of  calomel  every  hour  as  soon  as  the  patient 
recovers  consciousness,  following  it  next  day  with  a  saline 
purge  or  an  oxgall  enema,  or  both.  In  addition  to  this, 
when  reversed  peristalsis  becomes  alarming,  one  milligram 
of  eserine  salicylate  every  hour  may  be  g'iven  hypoder- 
mically  four  times.  And  above  all,  the  stomach  must 
be  washed  out  twice  daily  with  normal  salt  solution. 

But — a  paralytic  condition  of  the  bowel  may  arise 
which  is  not  of  septic  origin:  rough  handling,  prolonged 
exposure  of  the  intestines  to  the  air,  and  the  prolongation 
of  the  intestinal  inertia  naturally  following  any  extensive 
intraabdominal  operation  may  be  followed  by  failure  of 
the  bowels  to  move.  This  paralysis  of  the  intestine  is 
said  to  be  due  to  inhibition  from  stimulation  of  the  fibers 
of  the  splanchnic  nerves,  or  from  ovcrstimulation  result- 
ing in  fatigue  of  the  ganglia  in  Auerbach's  arid  Meissner's 
plexuses.  Hence  to  overcome  this  paresis  of  the  muscles 
essential  to  peristalsis,  stimulation  of  the  sympathetic 
and  spinal  centers  is  imperative.  Here,  then,  the  injection 
of  the  eserine  salicylate  works  more  effectively  than  in 
septic  paralysis;  and  two  milligrams  of  strychnine  sul- 
phate hypodermically,  every  six  hours,  must  add  to  its 
efficiency.  The  saline  laxative,  also,  is  indicated;  the 


14  SURGICAL  THERAPEUTICS 

best  way  to  give  it  being  to  wash  out  the  stomach  with 
normal  salt  solution  and  then  pour  in  two  tablespoonfuls 
of  Epsom  salt  dissolved  in  as  little  water  as  possible,  repeat- 
ing it  in  four  hours.  An  enema  of  strong  alum  water 
also  tends  to  induce  a  downward  peristaltic  wave. 

2.  When  these  measures  do  not  result  in  free  move- 
ment of  the  bowels  and  arrest  of  vomiting,  the  condition 
is  a  very  grave  one,  because  the  trouble  is  either  sepsis 
or  due  to  some  mechanical  obstruction,  the  one  not  to 
be  benefited   by  secondary  operation,  the   other  perhaps 
curable  by  early  interference.     Of  the  mechanical  impedi- 
ments the  most  easily  rectified  is  twisting,  or  kinking  of 
the  bowel,  technically  designated  volvulus.     This  is  easily 
distinguished    clinically   from    intestinal   paralysis,    septic 
or  otherwise,  by  the  fact  that  it  (like  all  the  mechanical 
obstructions)  is  accompanied  by  griping.     It  may  be  due 
to  kinking  in  returning  bowels  to  the  abdomen  or  by 
adhesion  of  two  surfaces  of  a  coil  of  gut  partially  or  wholly 
denuded  of  its  serosa.     It  is  most  likely  to  occur  in  the 
sigmoid;  so,  when  suspected,  copious  enemas  through  a 
high  rectal  tube  must  be  given  in  the  hope  that  the  intes- 
tine may  be  straightened.    This  failing,  immediate  reopen- 
ing of  the  belly  and  correction  of  the  difficulty  is  advis- 
able.    But — it  takes  a  vast  amount  of  courage  to  do  this, 
particularly  in  the  face  of    opposition    from  the  family 
and  the   criticism   that    "something  was    done  wrong." 
Yet  there  should  be  no  delay  when   the  indication  seems 
clear — many  lives  have  been  saved  by  such  brave  opera- 
tive work. 

3.  During  operation  a  hole  may  be  torn  in  the  mesen- 
tery,  through  which  a  loop  of  intestine  may  slip  and 
become  attached  in  some  way  so  as  to  produce  fatal  inter- 
nal hernia;  or  the  intestine  may  crawl  in  between  the  uterus 
and  belly-wall  hi  ventral   fixation  and  be   caught   with 
like  result.     Such  condition  may,  necessarily,  be  relieved 


ABDOMINAL  SECTION  15 

only    by   reopening    the    abdomen     and    correcting    the 
trouble. 

4.  Thrombosis  of  the  intestinal  vessels  is  far  more 
common  than  generally  suspected.  By  reason  of  faulty 
technic  the  mesenteric  vessels  may  be  injured  in  such 
way  that  the  blood  supply  of  a  considerable  area  of  gut  is 
cut  off  and  localized  gangrene  with  fatal  perforation 
follows.  Or  by  tearing  adhesions  around  abscesses, 
tumors,  etc.,  the  operator  may,  without  fault,  so  injure 
these  vessels  that  thrombosis  follows.  On  opening  the 
abdomen  for  this  complication  there  will  generally  be 
found  a  lot  of  dark-colored  fluid  (with  fecal  odor  if  per- 
foration has  already  occurred);  hence  copious  irrigation 
is  advisable,  one  of  the  few  instances  in  which  water  is 
of  use  in  the  abdomen.  If  the  general  condition  of 
the  patient  will  permit,  resection  of  the  bowel  should 
be  made — the  enterorrhaphy  being  well  beyond  the 
area  of  possible  extension  of  gangrene — by  means 
of  a  Murphy  button.  Generally  the  condition  of  the 
patient  is  such  that  extreme  haste  is  imperative;  in  which 
case  it  is  best  merely  to  bring  the  affected  loop  well  out 
of  the  abdomen,  irrigate  the  belly,  dry  it,  pack  gauze  in 
around  the  extruded  intestine  sufficiently  tight  to  prevent 
more  gut  from  being  forced  out,  then  clamp  healthy  gut 
above  and  below  the  dying  portion  and  cut  away  all  of 
the  necrotic  part  and  a  little  more,  tying  the  bleeding  ves- 
sels with  fine  catgut.  The  clamp  on  the  upper  extremity 
of  the  cut  intestine  may  be  removed  in  twenty-four  to 
forty-eight  hours  and  the  bowels  allowed  to  move  into 
cotton.  If  this  artificial  anus  be  high  in  the  ileum  or 
jejunum  it  will  be  necessary  to  make  a  secondary  opera- 
tion within  a  few  days — as  soon  as  the  patient  is  out  of 
immediate  danger.  The  best  operation  is  to  invert  the 
ends  of  the  gut,  sew  them  over  by  at  least  one  row  of  Lem- 
bert  sutures  (two  rows  are  better  on  the  upper  portion 


16  SURGICAL  THERAPEUTICS 

of  gut  as  the  point  of  closure  has  to  withstand  the  force 
of  the  entire  fecal  stream)  and  then  make  a  wide 
lateral  anastomosis,  the  belly  to  be  closed  without 
drainage. 

5.  Among  the  causes  of  failure  to  act  must  be  men- 
tioned inclusion  of  a  part  of  the  bowel  in  a  ligature  or 
suture.  Rarely  the  rectum  has  been  ligated  and  cut  across 
by  mistake,  the  error  in  technic  being  demonstrable  at 
the  postmortem  examination;  occasionally  other  por- 
tions of  the  intestine  have  been  similarly  mistreated;  but 
most  often  a  needle  is  thrust  through  a  small  section  of 
the  sigmoid  in  ligating  the  broad  ligament  or  a  little  of 
the  small  intestine  is  caught  in  the  suture  when  the  peri- 
toneum is  being  closed.  In  such  cases  the  bowels  have 
a  singular  inclination  not  to  move,  however  much  they 
may  be  encouraged  by  enemata  and  purgatives,  even 
though  there  is  not  the  slightest  leakage  at  the  point  of 
local  injury. 

Correction  of  the  difficulty  by  secondary  operation  is 
the  only  treatment;  but  the  patient  usually  dies  even  when 
the  source  of  trouble  is  removed  early.  Wounding  of 
the  bowel  may  occur  during  the  separation  of  adhe- 
sions; and  unless  this  is  noted  at  the  time  and  the  injury  at- 
tended to  by  proper  closure  of  the  opening,  fatal  sepsis  may 
result;  or  an  obstruction  of  the  bowel  may  seem  to  be  pres- 
ent by  reason  of  nature's  arresting  persitalsis  while  adhe- 
sions form  as  an  effective  barrier  against  leakage.  When 
such  a  condition  is  suspected  (as  when  extensive  adhe- 
sions have  been  roughly  separated  deep  in  the  pelvis)  it 
is  far  better  to  keep  the  patient  absolutely  quiet  by  large 
doses  of  morphine  than  to  give  cathartics,  etc.,  in  the  vain 
hope  of  securing  early  bowel-movement.  When  it  is 
known  that  the  bowel  is  injured,  as  in  removal  of  the 
appendix,  closure  of  intestinal  wounds,  etc.,  it  is  best 
not  to  try  to  force  peristalsis;  rather  is  it  advisable  to 


ABDOMINAL  SECTION  17 

give  enough  opiates  to  prevent  bowel-movement  for  at 
least  two  days — and  three  are  better. 

Another  surgical  interference  with  peristalsis  is  too 
close  packing  of  the  pelvis,  or  sometimes  other  parts  of 
the  peritoneal  space:  the  bowel  is  pressed  between  the  pack 
and  the  hard  walls  or  is  caught  in  the  folds  of  gauze  as 
they  are  jammed  in  to  control  oozing,  and  a  mechanical 
obstruction  of  the  bowel  is  produced.  Fortunately  pack- 
ing is  generally  removed  within  forty-eight  hours  and  the 
bowels  then  take  care  of  themselves;  but  sometimes  symp- 
toms of  obstruction  persist  after  the  tampon  is  removed 
and  it  then  becomes  necessary  to  reopen  the  wound  and 
overcome  the  difficulty,  if  possible,  by  liberation  from 
bands,  resection  of  gut  if  pressure-necrosis  has  arisen  or 
formation  of  an  artificial  anus  as  a  dernier  ressort. 

Rough  handling  of  the  intestines,  too,  may  cause 
such  abrasion  of  the  serosa  that  the  intestine  may  attach 
istelf  to  some  raw  surface  and  in  this  way  become  fixed 
even  if  not  twisted,  and  so  give  rise  to, serious  symptoms 
of  obstruction;  for  which  reason  the  intestines  should  be 
handled  in  soft  gauze  pads  instead  of  the  hands  or  retrac- 
tors, and  not  subjected  to  wiping.  The  obstruction 
from  this  source  is  more  likely  to  be  late:  probably  months 
after  operation — stricture  or  bands  or  twist  being  found 
when  the  abdomen  is  opened. 

6.  Not  infrequently  certain  conditions  existing  before 
operation  are  not  recognized  during  the  excitement  of 
the  work  and  so,  uncorrected,  lead  to  obstruction.  This 
is  conspicuously  the  case  in  adhesions  of  the  gut  around 
the  infected  areas  of  an  appendicitis;  death  from  obstruc- 
tion of  the  bowels  occurs  quite  often  in  appendicitis  oper- 
ated upon  at  the  height  of  the  inflammatory  process, 
hence  the  advice  to  operate  during  the  first  forty-eight 
hours  of  the  disease  or  else  let  the  case  go  on  until  the  eighth 
to  tenth  day,  when  the  abscess  is  well  walled  off  and  the 


18  SURGICAL  THERAPEUTICS 

conditions  such  that  they  can  be  met  without  danger  of 
injury  to  contiguous  gut  by  packing,  tearing  etc.  Adhe- 
sions around  an  inflamed  gall-bladder,  too,  may  not  be 
discovered,  and  a  tight  packing  induce  acute  angling  of 
the  colon  or  ileum  with  immediate  obstruction.  Also,  in  cer- 
tain conditions  there  may  be  an  obstruction  (from  impacted 
feces,  from  inflammatory  bands,  etc.)  just  beginning 
at  the  time  of  operation,  perhaps  the  obstruction 
rather  than  the  disease  being  productive  of  the  acute 
symptoms — vomiting,  collapse  and  so  on — and  the  obstruc- 
tion not  being  discovered  death  may  follow  although 
the  pathological  condition  for  which  operation  was  under- 
taken may  have  been  perfectly  remedied. 

Obstruction  of  the  bowels  may  appear  late,  after  the 
patient  has  returned  home  and  is  considered  perfectly 
well — strictures,  bands,  adhesions  and  scar-contractions 
causing  it.  For  the  prevention  of  this  the  experienced 
abdominal  surgeon  has  learned  to  cover  all  denuded 
points  with  peritoneum,  when  possible,  even  the  omentum 
being  stitched  over  any  raw  surface  which  cannot  other- 
.wise  be  protected. 

But  whatever  symptoms  of  'obstruction  appear,  how- 
ever late,  the  wise  surgeon  opens  the  belly  and  corrects 
the  cause  at  the  earliest  moment  the  patient  will  consent 
to^operative  work.  Inability  to  secure  bowel-movement, 
followed  by  vomiting  which  changes  from  merely  bile- 
stained  to  strecoraceous,  and  not  relieved  by  gastric  lavage, 
especially  if  associated  with  distension  of  the  abdomen 
and  griping,  cannot  be  mistaken;  they  form  a  grouping 
of  symptoms  invariably  meaning  mechanical  obstruction, 
and  just  as  certainly  indicating  immediate  operative  work. 
To  wait  until  collapse  appears  is  a  crime;  it  spells  death 
in  most  cases. 

In  the  possibility  of  encountering  postoperative  dif- 
ficulties such  as  these  lies  the  incentive  to  refer  patients 


ABDOMINAL  SECTION  19 

to  experienced  operators  rather  than  subject  them  to 
the  hands  of  the  "county-seat  surgeon."  Every  such 
operator  should  be  prepared  to  open  the  abdomen  in 
any  case  of  emergency:  acute  appendical  rupture,  strangu- 
lated hernia,  intussusception  and  even  cesarean  section; 
but  when  it  comes  to  an  operation  of  choice,  where  the 
patient  can  be  sent  to  a  good  hospital  and  secure  the  serv- 
ices of  a  skilful  operator  who  has  (a)  become  possessed 
of  great  anatomical  knowledge,  (b)  who  has  been  taught 
much  pathology,  (c)  who  has  spent  months  assisting 
some  master  of  abdominal  surgery,  and  (d)  who  has  by 
the  successful  management  of  many  hundreds  of  cases  in 
his  own  work  learned  not  only  to  overcome  operative 
difficulties  readily  but  also  to  carry  the  patient  through 
the  dangerous  postoperative  days,  it  is  little  less  than 
criminal  to  permit  the  inexperienced  or  infrequent  opera- 
tor to  open  the  abdomen.  The  doctor  who  will  permit 
some  ambitious  friend  to  make  the  operation  "for  experi- 
ence" (unless  he  has  had  the  advantages  already  speci- 
fied) or  to  gain  local  prestige  as  a  surgeon  is  taking  dan- 
gerous liberties  with  the  life  of  the  patient  who  has  trusted 
him.  Entirely  too  many  bellies  are  being  opened  by 
inexperienced  "surgeons." 

Preparation  for  Abdominal  Section, — Whenever 
possible,  a  good  cathartic  should  be  given  the  day  before 
operation  (a  saline  being  preferable)  in  such  quantity  that 
five  or  six  good  bowel-movements  are  secured.  On  the 
morning  of  the  day  before  operation  the  skin  of  the  entire 
abdominal  wall  should  be  scrubbed  and  shaved;  and  a. 
soap  poultice  applied.  In  the  evening  the  poultice  should 
be  removed,  the  skin  again  scrubbed  and  washed  with  alco- 
hol, and  a  bichloride  pack  (i  in  2000  solution)  bound  on 
for  the  night.  This  is  to  be  removed  after  the  patient  is 
on  the  operating  table;  the  skin  again  scrubbed  with  soap 
and  water,  dried  with  a  sterile  towel,  washed  carefully 


20  SURGICAL  THERAPEUTICS 

with  sulphuric  ether  to  remove  the  fat,  then  rubbed  vigor- 
ously with  gauze  saturated  with  65-percent  alcohol,  and 
finally  rinsed  with  bichloride  solution,  i  in  2000.  The  field 
of  operation  is  then  to  be  surrounded  with  towels  just 
out  of  the  boiler  (wrung  dry  as  convenient)  held  in  place 
by  safety-pins  which  have  been  boiled  with  the  instruments; 
and  then  a  sterile  towel  may  be  placed  temporarily  over  all 
while  final  arrangements  (if  any)  are  made. 

Unfortunately  in  many  cases  it  is  impossible  to  make 
the  preliminary  preparation,  as  in  accidents,  strangulated 
hernia  and  the  like;  in  which  cases  the  scrubbing  must  be 
done  with  unusual  care. 

ABSCESSES, 

Definition. — Technically  an  abscess  is  the  formation 
of  pus  in  some  cavity  of  the  body,  the  result  of  an  in- 
flammation, i.  e.,  infection  by  one  of  the  pyogenic  bacteria; 
but  practically  the  name  is  applied  to  any  localized  ac- 
cumulation of  pus. 

Alveolar  Abscess. — An  abscess  in  the  gums  or  alveo- 
lus must  be  opened  as  soon  as  found,  and  the  mouth 
kept  as  clean  as  possible  by  frequent  washings  with  dilute 
hydrogen  dioxide  or  a  saturated  solution  of  potassium 
chlorate  in  water.  If  a  small  spicule  of  the  alveolar  proc- 
ess be  the  cause  of  the  trouble,  it  should  be  removed 
after  incision,  by  a  minute  curet  or  by  pincers.  If  due  to  a 
decayed  root,  the  offending  tooth  must  be  pulled.  An 
antiseptic  mouth-wash  will  soon  complete  the  cure. 

Bursal  Abscess. — Any  of  the  bursae  may  become  the 
seat  of  an  infection  with  pus-germs,  the  bursa  of  the  quad- 
riceps extensor  being  most  frequently  affected  ("house- 
maid's knee").  If  the  pus-infected  sac  has  become  shut 
off  from  the  near-by  joint  by  an  adhesive  inflammation,  all 
that  is  essential  in  treatment  is  free  incision,  packing  with 
gauze  (renewed  every  two  or  three  days)  until  the  cavity 


ABSCESSES  21 

closes  from  the  bottom,  with  granulations.  If  there  be 
a  suspicion  that  the  abscess  is  of  tubercular  origin,  the 
sac  when  first  opened  may  be  swabbed  thoroughly  with 
tincture  of  iodine,  and  iodoform  gauze  used  for  packing. 
When  the  neighboring  joint  is  involved  in  the  suppurative 
process,  only  the  freest  of  incision  and  perfect  drainage  will 
save  the  limb  from  amputation. 

Cerebral  Abscess. — Abscess  of  the  brain  may  follow 
injury  to  the  head,  or  it  may  arise  from  suppuration,  near 
or  far:  conspicuously  from  otitis  media.  When  headache, 
fever  like  that  of  meningitis,  oncoming  coma  and  optic 
neuritis  are  noticed,  the  greatest  care  should  be  exercised 
to  determine  the  existence  and  location  of  cerebral  suppura- 
tion, and  trephine.  Middle-ear  disease  associated  with 
these  symptoms  justifies  exploratory  trephining  one  inch 
and  a  quarter  above  and  an  inch  behind  the  meatus 
externus.  The  abscess,  if  found,  is  evacuated  and  drained 
the  same  as  in  any  other  location. 

Cold  Abscesses. — These  develop  slowly,  without  fever 
or  pain — commonly  about  joints,  bones  or  glands.  They 
are  not  true  abscesses  because  they  are  not  due  to  inflam- 
mation (i.  e.,  infection  with  germs  of  true  pus)  but  are  es- 
sentially tuberculous  (which  see). 

Fecal  Abscesses. — If  these  form  about  the  rectum  from 
perforation,  they  may  work  downward,  becoming  "ischio- 
rectal"  abscesses  (which  see).  But  when  they  occur  from 
perforation  of  the  gut,  higher  in  its  course — as  from  per- 
foration of  Fever's  patches  in  typhoid,  of  the  cecum  from 
typhlitis  or  appendicitis,  from  tuberculous  ulcers  anywhere 
— huge  accumulations  of  pus  may  result;  gallons  escaping 
occasionally  when  the  abdomen  is  opened.  Rarely  they 
are  not  protected  by  adhesions  to  the  parietes,  being 
located  between  adherent  coils  of  intestines  and  omentum; 
under  these  circumstances  they  are  very  dangerous  dna 
difficult  to  handle.*  Usually  they  may  be  emptied  without 


22  SURGICAL  THERAPEUTICS 

opening  the  free  peritoneum;  packing  without  irrigation 
sufficing  to  cure. 

Mammary  Abscesses, — These  form  during  the  prog- 
ress of  an  inflammation  of  the  breast.  (See  "Mastitis.") 

Metastatic  Abscesses. — Secondary  (socalled  "meta- 
static")  abscesses  are  those  developed  at  a  distance  from 
the  seat  of  primary  infection.  They  are  invariably  septic, 
from  an  infected  embolus;  often  they  are  multiple  and  small, 
called  miliary  abscesses,  prominently  noticeable  in  the 
lungs.  When  accessible,  they  must  be  incised  freely  and 
perfect  drainage  maintained  until  they  heal  by  granulation 
from  the  bottom. 

Pain  of  Abscesses. — For  the  relief  of  the  pain  of  a 
forming  abscess  or  carbuncle,  belladonna  is  more  effica- 
cious than  opium.  Ichthyol  seems  also  to  possess  remark- 
able properties  of  similar  effect.  A  most  excellent  pre- 
scription is: 

Ichthyol 10.0 

Extract  of  belladonna   40.0 

Glycerin 50.0 

Mix.  Smear  on  flannel  abundantly,  apply  to  the  sore, 
and  cover  with  oiled  silk,  a  pad  of  cotton  and  a  bandage. 
It  may  be  changed  every  three  or  four  hours.  It  is  claimed 
that  abscesses  can  usually  be  aborted  by  saturating  the  pa- 
tient with  nuclein  or  with  the  sulphides  of  arsenic  and  lime. 

Psoas  Abscesses. — These  are  not  true  abscesses,  as 
a  rule,  until  after  they  are  opened.  The  contents  consist 
of  the  debris  from  destruction  of  a  lumbar  or  a  lower  dorsal 
vertebra  by  tuberculosis,  the  liquefied  matter  descending 
within  the  sheath  of  the  psoas  muscle  and  "pointing"  in 
Scarpa's  triangle.  If  opened,  they  quickly  become  infected 
with  true  pus-microbes  and  chronic  sepsis  follows;  hence 
the  advice  to  empty  by  aspiration  (under  strictest  antiseptic 
precautions)  rather  than  by  incision.  lodoform  emulsion 
is  sometimes  injected  but  it  is  doubtful  if  it  is  ever  followed 


ABSCESSES  23 

by  abatement  of  any  symptom;  it  certainly  cannot  reach 
and  affect  the  source  of  the  trouble. 

Spinal  Abscesses. — "\Yhen  abscesses  form  in  Pott's 
disease  of  the  spine  the  abscesses  which  contain  only  tuber- 
cular liquefication  should  be  aspirated.  When  true  pus 
has  formed,  aseptic  thorough  drainage  is  advisable. 

Stitch  Abscesses. — Around  sutures  in  an  otherwise 
uninfected  wound  there  may  be  little  points  of  suppuration : 
infection  from  the  staphylococcus  epidermidis  albus  of  an 
imperfectly  cleaned  field  of  operation.  In  removing  stitches 
on  the  eighth  to  the  twelfth  day,  if  any  are  noted  as  sur- 
rounded by  this  wrhitish  pus,  they  must  be  left  until  all 
non-infected  ones  are  taken  out,  then  the  clean  stitch- 
holes  carefully  covered  with  gauze  and  the  infected  sutures 
cut  and  withdrawn.  The  pus  must  then  be  gently  pressed 
out  and  wiped  away  by  gauze.  If  hydrogen  dioxide  or 
other  liquid  is  poured  over  them  the  germs  will  be  carried 
to  the  other  holes  and  general  infection  of  the  wound 
induced;  so  it  is  best  just  to  empty  them  and  apply  bi- 
chloride gauze  over  the  cut.  If  this  be  an  extensive  one 
it  should  be  supported  by  a  few  strips  of  adhesive  plaster 
over  the  gauze. 

Sometimes  in  spite  of  all  precautions  there  is  pus- 
infection  of  all  the  stitch-hole  openings.  These  should  be 
enlarged  or  the  cut  opened  at  two  or  more  points  to  secure 
drainage.  As  a  rule  these  wounds  do  best  if  simply  wiped 
out  carefully  with  absorbent  cotton  on  a  probe  or  wooden 
tooth-pick  and  then  covered  with  dry  gauze  without  rubber 
or  oiled-silk  protective.  Dusting  powders  cause  retention 
of  the  pus  under  the  artificial  scab  and  liquid  antiseptics 
often  irritate  and  retard  healing. 

Stitch  Abscesses  from  Bacilli  Coli  Commtmis. — 
During  an  operation  for  gallstones,  cholecystitis,  appendi- 
citis, infected  ovarian  tumor  or  other  condition  in  which 
the  bacillus  coli  communis  is  the  causative  pathogenic  micro- 


24  SURGICAL  THERAPEUTICS 

organism,  a  trifle  of  the  pus  or  infected  blood-serum  or 
mucus  may  come  in  contact  with  the  raw  surface  of  the 
wound  in  the  abdominal  parietes.  If  the  cut  be  sewed 
without  drainage  there  may  be  no  risfe  in  temperature, 
and  the  operator  flatters  himself  that  he  has  no  wound 
infection.  Yet  on  opening  the  dressings  on  the  tenth  or 
eleventh  day  he  finds  every  stitch-hole  oozing  pus  and 
on  separating  the  margins  of  the  incision  at  one  or  two 
places  several  drams  of  pus  may  be  squeezed  out.  If  this 
is  a  pure  colon-bacillus  infection,  in  addition  to  the  pecu- 
liar absence  of  fever  the  wound  will  be  found  free  from  the 
redness  and  excessive  tenderness  characteristic  of  staphylo- 
coccus  infection.  If  the  pus  be  pressed  out  carefully  the 
wound  will  quickly  heal;  but  if ,  by  carelessness  in  handling, 
a  staphylococcus  infection  is  engrafted,  a  long  and  tedious 
suppuration  may  follow,  with  fever  and  pain. 

Thecal  Abscess. — The  sheath  of  a  tendon  may  be- 
come the  site  of  an  abscess,  which  is  prone  to  infect  the 
joint  through  which  it  passes.  The  earliest  possible  evacua- 
tion by  free  incision  is  the  only  treatment.  Packing  with 
gauze  saturated  with  a  solution  of  equal  parts  of  "gum" 
camphor  and  pure  phenol  seems  to  prevent  extension  of 
inflammation  and  to  promote  healing. 

Tropical  Abscess. — Acute  hepatitis  ending  in  the 
formation  of  abscess — very  frequent  in  the  tropics,  hence 
the  name  "tropical  abscess" — must  be  treated  by  early 
incision  and  free  drainage.  Usually  this  can  be  done  with- 
out invading  the  non-infected  peritoneal  space,  as  adhesion 
between  Glisson's  capsule  and  the  parietal  serosa  has  given 
ample  protection.  If  no  adhesions  have  formed,  one  of  two 
things  may  be  done:  (a)  A  large  opening  may  be  made 
and  several  pieces  of  gauze  (each  2  by  6  or  8  inches) 
packed  in  between  the  liver  and  parietal  peritoneum; 
adhesions  forming  in  two  or  three  days,  secondary  incision 
may  be  made  in  the  liver  without  danger  of  peritonitis; 


ABSCESSES  25 

or  (b)  if  the  necessity  seems  urgent  for  immediate  evacuation 
much  gauze  may  be  packed  around  the  proposed  opening 
so  as  to  prevent  any  pus  from  escaping  intothe  peritoneal 
space  and  the  abscess  freely  opened.  When  emptied  the 
cavity  is  to  be  packed  with  gauze,  held  firmly  in  place  by 
an  assistant,  the  contaminated  protective  gauze  with- 
drawn and  fresh  gauze  crowded  in  very  tightly  in  every 
direction  for  at  least  two  inches  beyond  the  margins  of 
the  abdominal  cut.  In  a  few  hours,  happily  before  the  pus 
accumulates  in  the  gauze-packing  enough  to  "run  over," 
a  protective  barrier  of  adhesions  will  have  formed;  but  so 
fragile  that  the  gauze  must  not  be  removed  before  the 
fourth  day. 

Tubercular  Abscesses. — When  an  enlarged  lymph- 
gland  softens  and  shows  evidence  of  forming  an  abscess 
two  plans  are  open  to  choice.  If  scarring  is  very  unde- 
sirable the  skin  may  be  properly  cleaned  by  scrubbing, 
application  of  ether  and  then  washing  with  alcohol;  then 
a  large  aspirator-needle  thrust  into  the  gland  and  the  broken- 
down  tuberculous  material  withdrawn;  finally  about  2 
grams,  half  a  teaspoonful,  of  lo-percent  iodoform  emulsion 
injected  and  the  opening  closed  with  collodion  and  an 
antiseptic  dressing.  In  most  cases,  though,  the  best  treat- 
ment is  to  prepare  the  skin  as  above,  make  an  opening 
of  a  half  inch  or  more,  let  out  the  pus  (using  a  knife  care- 
fully sterilized)  and  curet  with  a  surgically  clean  Volk- 
mann's  spoon;  then  burn  the  interior  thoroughly  with  pure 
phenol,  instantly  neutralized  by  pure  alcohol;  insert  a  few 
strands  of  catgut  and  cover  with  a  large  antiseptic-gauze 
pad  to  be  left  undisturbed  for  two  weeks.  If  these  steps 
be  taken  with  perfectly  clean  hands  and  field  of  opera- 
tion and  with  sterile  instruments,  healing  will  be  by  primary 
union,  with  a  slight  scar  only  which  will  not  be  visible  after 
a  year's  time.  If  pus  ooze  through  the  dressing  or  if 
fever  arise  after  several  days,  infection  with  staphylococcus 


26  SURGICAL  THERAPEUTICS 

aureus  or  albus  may  be  taken  for  granted  and  a  dressing 
made — with  bad  scarring  to  be  feared. 

"Washing  Out"  Abscesses. — The  idea  that  abscesses 
and  infected  wounds  healing  by  granulation  must  be 
washed  out  with  some  antiseptic  solution,  notably  hydro- 
gen dioxide,  seems  to  die  hard.  If  an  abscess  be  freely 
opened  and  properly  drained  by  a  loose  bit  of  gauze  (even 
the  abominable  rubber-tube,  which  so  retards  healing 
and  helps  establish  a  permanent  sinus,  is  better  than 
nothing)  and  if  an  open  infected  sore  be  dressed  with  fresh 
gauze  as  often  as  the  old  becomes  soiled,  nature  will 
do  all  the  irrigating  needed.  It  is,  of  course,  desirable 
to  dress  a  suppurating  wound  every  day,  from  a  financial 
standpoint,  if  the  patient  pay  well  for  each  dressing;  but 
surgically  the  less  often  a  granulating  surface  is  disturbed 
the  better  and  quicker  it  will  heal.  Sometimes  an  open 
sore  will  do  better  redressed  only  twice  a  week;  and  then 
the  granulations  must  be  disturbed  as  little  as  possible — 
the  pus  must  never  be  rubbed  away.  Most  wounds  do 
best  when  sublimate  gauze,  i  in  2000,  is  used. 

ACETONURIA. 

This  has  been  attracting  considerable  attention  of 
late  because  it  is  claimed  that  some  deaths  following  inha- 
lation of  ether  are  due  to  it  rather  than  the  anesthetic. 
Acetone  is  found  hi  small  quantities  hi  the  blood  and  in 
normal  urine,  but  it  is  very  abundant  in  certain  stages 
of  diabetes,  and  sometimes  follows  high  fever. 

Acid  states  of  the  urine  are  very  important  in  surgery, 
without  doubt;  and  if  urinary  analysis  prior  to  opera- 
tion shows  an  abnormality  (particularly  diabetes),  there 
should  be  great  hesitancy  about  performing  operations 
not  absolutely  imperative.  The  dangers  of  acetonuria, 
too,  should  be  kept  in  mind  when  contemplating  opera- 
tion upon  patients  suffering  from  profound  mental  depres- 


ACETONURIA  27 

sion,  especially  melancholia,  since  it  has  been  shown 
that  imperfect  oxidation  underlies  most  of  the  depressed 
psychoses,  like  melancholia,  and  the  depressed  phases  of 
the  compound  psychoses;  that  acetone,  diacetic  acid  and 
betaoxybutyric  acid  arise  from  suboxidization.  In  epilepsy 
and  paretic  dementia,  too,  there  is  the  same  imperfect 
oxidation;  but  in  diabetes  it  is,  of  course,  worse. 

Therefore,  in  all  such  cases  before  operation  careful 
uranalysis  should  be  the  universal  rule.  The  normal 
degree  of  urinary  acidity  is  from  30°  to  45°;  if  it  fall  below 
30°,  either  there  is  imperfect  production  of  the  acid  or 
imperfect  elimination.  In  the  first  event  imperfect  oxida- 
tion is  present;  in  the  latter,  acid-accumulation  with  all 
its  possibilities  is  imminent.  (Butler.) 

In  insanity  due  to  head-injury  a  period  of  seeming 
mental  quiescence  may  be  followed  by  attacks  of  vomit- 
ing, purging,  semicoma,  and  return  of  insanity;  the  rash 
surgeon  wishes  to  operate;  but — examination  shows 
urinary  acidity  of  as  low  as  10°;  after  subsidence  of  the 
acute  symptoms,  under  eliminative  treatment, 'the  acidity 
will  increase  to  45°;  then  operation  is  safe.  The  same 
phenomena  have  been  noted  following  heat-stroke  and 
severe  shocks  of  electricity;  so  if  operation  be  indicated 
after  either  of  these,  the  urine  must  be  examined,  and  if 
found  deficient  in  acidity,  postponement  is  advisable. 

Patients  presenting  acetonuria  as  a  prominent  fea- 
ture after  operation  pass  urine  of  a  marked  "fruity"  odor 
(likened  by  some  to  the  smell  of  chloroform),  cannot  be 
aroused  and  finally  die  in  coma.  This  is  especially  likely 
to  occur  after  cancer,  a  disease  prone  to  the  formation  of 
excessive  quantities  of  acetone.  Bicarbonate  of  sodium 
is  perhaps  the  best  drug  to  employ,  plus  laxatives.  In 
diabetes  prompt  relief  follows  a  free  use  of  carbohydrates. 
When  acetonuria  is  recognized  hypodermoclysis  is  advisable, 
plus  pilocarpine  hypodermically  every  six  hours. 


28  SURGICAL  THERAPEUTICS 

ACHONDROPLASY. 

This  is  a  name  given  by  Parrott  to  a  -form  of  feta 
rickets  in  which  the  limbs  are  short  and  their  bone 
curved  where  they  should  be  straight,  and  the  natura 
curves  exaggerated,  with  absence  of  the  proliferatin 
zone  of  cartilage  at  the  junction  of  the  epiphyses.  It  i 
very  like  fetal  cretinism.  Fortunately  most  of  such  chil 
dren  are  born  dead.  Should  they  survive,  syrup  c 
hypophosphites  may  be  given  ad  libitum.  Later,  attempt 
may  be  made,  as  in  rickets,  to  correct  the  deformities. 

ACROMEGALIA. 

This  is  a  condition  (or  disease)  characterized  by  ai 
abnormal  development  of  the  extremities  (bones  as  we] 
as  soft  parts)  and  of  the  face.  It  is  of  long  duration— 
the  patient  finally  dying  of  exhaustion  after  ten  to  twent; 
years.  Virchow  claimed  it  to  be  hereditary.  Nothinj 
is  known  of  its  cause;  and  of  therapy  there  is  none  excep 
attention  to  the  general  health  of  the  individual,  tonic 
and  good  food  prolonging  life.  Nothing  can  be  dom 
for  the  deformity. 

ACTINOMYCOSIS. 

When  the  actinomycosis  bovis — the  ray-fungus — by  an] 
accident  is  introduced  into  the  human  system,  then 
results  a  peculiar  disease  distinguished  by  the  develop 
ment  of  a  peculiar  afebrile  inflammation,  with  or  with 
out  suppuration,  but  often  giving  rise  to  granulation 
tumors.  Abscesses  about  the  jaws  and  teeth  are  th< 
most  frequent  and  the  most  curable  of  its  manifestations 
Actinomycotic  tumors  of  the  neck  are  very  ugly. 

In  making  a  diagnosis  one  must  remember  that  the 
cases  are  grouped  in  four  classes:  (i)  Head  and  necfc 
actinomycosis,  with  infection  from  mouth  and  pharynx 
(2)  chest  actinomycosis,  i.  e.,  infection  through  the  res- 


ACTINOMYCOSIS  29 

piratory  tract;  (3)  abdominal  actinomycosis,  with  infec- 
tion probably  always  through  the  alimentary  canal,  pos- 
sibly through  the  genital  tract  in  the  female;  (4)  actinomy- 
cosis of  the  skin. 

The  only  treatment  of  actinomycosis  is  prompt  removal 
of  the  affected  tissues.  When  the  parasite  is  located  in 
the  liver  or  stomach-wall  no  treatment  will  do  any  good. 
Iodide  of  potassium  may  be  given  after  operation. 

Actinomycosis  of  Abdomen. — Friederich  found  that 
4  percent  of  all  patients-  operated  on  for  appendicitis  at 
Greifswald  during  three  years  were  of  actinomycotic 
origin.  Of  the  eight  patients  treated  by  removal  of  all 
diseased  tissue,  the  incision  extending  into  the  healthy 
parts,  seven  are  at  present  in  apparent  good  health.  The 
experience  in  former  cases  has  been  that  the  condition  is 
liable  to  recur  after  two  or  three  years  of  apparent  cure. 

Actinomycosis  of  the  Appendix. — Strange  to  say, 
actinomycosis  may  affect  the  vermiform  appendix.  The 
fungus  of  streptothrix  (actinomyces)  enters  the  body 
by  the  alimentary  canal  and  may  attack  the  appendix 
in  one  of  two  ways:  (a)  as  a  simple  streptothrix  infection, 
or  (b)  as  a  mixed  infection  with  staphylococci  or  colon 
bacilli. 

In  the  first  the  symptoms  closely  resemble  those  of 
any  other  appendicitis;  in  the  second  form  they  are  much 
more  severe:  rigors  and  septic  'pyelophlebitis  being  rela- 
tively common,  although  quite  rare  in  ordinary  suppura- 
tion about  the  appendix.  The  points  of  value  in  arriv- 
ing at  a  diagnosis  of  non-suppurating  streptothrix  infection 
of  the  appendix  are  a  long  history  of  slight  indefinite 
pain  in  the  appendical  region,  the  relatively  large  amount 
of  induration,  and  if  operation  is  performed,  the  small 
quantity  of  broken-down  material.  In  the  suppurating 
form  the  early  occurrence  of  rigors  and  the  pointing  of 
abscesses  at  a  distance  from  the  appendix  are  in  favor 


30  SURGICAL  THERAPEUTICS 

of  actinomycosis.  Early  operative  treatment  in  con- 
nection with  free  drainage,  with  the  long  administration 
of  large  doses  of  iodide  of  potassium  or  arsenic, 
is  advised. 

ADENITIS 

Adenitis  (Tuberculous)  Treated  by  X-Ray. — After 
a  careful  analysis  of  reports,  Boggs,  of  Pittsburg,  con- 
cludes that  in  the  treatment  of  tuberculous  glands  the 
results  obtained  by  the  use  of  Roentgen  rays  will  com- 
pare favorably  with  those  from  any  other  method,  as  a 
large  proportion  of  the  patients  can  be  (apparently) 
cured.  The  treatment  usually  requires  .  about  three 
months,  at  the  end  of  which  the  glands  have  undergone 
a  degeneration,  leaving  a  hard  fibrous  nodule,  which  as 
a  rule,  never  gives  any  further  trouble.  The  radiation 
must  necessarily  be  intense,  with  the  tube  placed  at  least 
12  inches  from  the  surface,  in  order  to  influence  the  whole 
of  the  diseased  area.  The  important  part  of  the  treatment 
is  to  have  a  tube  placed  the  proper  distance,  giving  off 
rays,  rich  chemically,  and  with  the  proper  degree  of  pene- 
tration. 

Iodine  for  Enlarged  Glands. — Enlarged  lymphatic 
glands  which  do  not  seem  inclined  to  break  down  into 
pus  may  sometimes  be  made  to  disappear  by  the  local 
use  of  the  official  iodine  ointment  (unguentum  iodi,  U. 
S.  P.).  When  ordered  for  children  who  have  a  very  deli- 
cate skin  it  should  be  diluted  one-half  with  lanolin.  It 
should  be  applied  with  gentle  friction  twice  daily.  This 
mode  of  using  iodine  is  preferable  to  painting  with  tinc- 
ture of  iodine  for  this  trouble.  But  the  treatment  must  be 
discontinued  as  soon  as  it  is  seen  that  pus  is  forming  and 
the  glands  excised  under  strictest  aseptic  precautions,  with 
greatest  care  that  the  enveloping  tissue  (capsule)  is  not 
broken  into. 


ADENITIS  31 

Scrofulous  Glands. — Under  this  term  the  older 
writers  described  a  peculiar  form  of  adenitis — an  enlarge- 
ment of  the  lympathic  glands,  usually  of  the  neck,  with 
a  tendency  to  become  chronic  and  to  develop  into  "cold 
abscesses,"  i.  e.,  formation  of  a  pus-like  material  without 
any  local  signs  of  inflammation  until  after  the  "abscess" 
has  been  discharging  for  some  time.  The  word  "scrofula" 
has  been  abandoned — these  glands  are  the  site  of  a  tuber- 
culous deposit;  the  "pus"  is  but  the  liquefaction  of  the 
caseous  product  of  bacterial  action,  and  "inflammation" 
occurs  only  when  there  is  inflammation  with  true  pyogenic 
microorganisms.  If  opened  under  absolute  asepsis  they 
heal  without  inflammation. 

Tuberculous  Glands. — Whenever  a  patient  will  consent, 
all  tuberculous  glands  should  be  removed  by  radical  opera- 
tion; this  being  notably  desirable  of  enlarged  cervical  glands. 
A  severe  blow  may  disseminate  the  tubercle  and  cause  a 
purely  local  deposit  to  give  rise  to  a  rapidly  fatal  general 
tuberculosis.  In  the  operation  both  the  superficial  and 
the  deep  lymphatics  must  be  extirpated — a  most  tedious 
operation  of  at  least  an  hour's  work,  as  the  dissection  must 
be  perfect  and  the  field  under  the  carotid  cleaned  out. 
The  aseptic  technic  must  be  as  free  from  fault  as  in  the 
most  serious  abdominal  section.  Drainage  may  be  made,  by 
inserting  several  strands  of  plain  catgut  to  the  depths  of 
the  wound  at  two  or  even  three  places.  The  large  anti- 
septic dressing  should  never  be  removed  until  the  twelfth 
day  unless  something  very  unusual  arises.  But  if  the 
patient  will  not  submit  to  operative  treatment  the  enlarged 
glands  may  be  rubbed,  gently,  each  night  with: 

Ichthyol 16  parts 

Benzoated  lard 64  parts 

Or  they  may  be  painted  every  second  day  with  decolorized 
tincture  of  iodine.  Internally  the  best  of  food  is  impera- 
tive, cream  being  especially  good;  if  not  obtainable,  cod- 


32  SURGICAL  THERAPEUTICS 

liver  oil  may  be  substituted.  Iron  and  arsenic  must  be 
administered  in  large  doses.  The  tonsils  should  invariably 
be  inspected  and  excised  if  presenting  any  sign  of  trouble, 
as  they  are  often  the  source  of  infection. 

ADENOIDS 

"Adenoid  vegetations"  is  an  expression  applied  to 
hypertrophy  of  the  glandular  tissue  normally  found  in 
the  nasopharynx.  When  excessively  developed  this  con- 
dition leads  to  mouth-breathing,  more  or  less  impairment 
of  hearing,  and  muffled  voice;  in  the  worst  cases  the  open 
mouth,  vacant  expression  of  face  and  general  listless- 
ness  are  unmistakable  to  the  trained  eye.  If  not 
corrected,  serious  mental  deficiency  may  result,  as  well 
as  enlargement  of  the  tonsils,  enuresis  and  mastur- 
bation, with  deleterious  influence  upon  the  bodily 
development. 

Under  chloroform  they  may  be  removed  by  curet  or 
even  by  the  finger-nail.  No  local  medication  will  do 
any  good.  Anesthesia  by  nitrous  oxide  or  by  ethyl  bro- 
mide answers  well  for  such  operations,  where  only  a  brief 
anesthetic  period  is  required. 

In  cases  of  only  mild  degree  with  but  slight  enlarge- 
ment of  the  tonsils,  a  weak  alkaline  solution,  such  as 
the  following  should  be  syringed  through  the  nose  and 
fauces  so  as  to  free  the  lymphoid  tissue,  so  far  as  pos- 
sible, from  microorganisms,  and  to  prevent  crusts  form- 
ing upon  the  surface: 

Sodii  bicarbonatis 0.4  (grs.  6) 

Boracis    0.4  (grs.  6) 

Sodii  chloridi 0.2  (grs.  3) 

Glycerini 4.0  (dr.    i) 

Aquae 30.0  (oz.    i) 

Misc.  Sig. :     Use  as  a  spray  freely  twice  daily. 


AINHUM  33 

Astringents,  such  as  the  following,  may  oe  painted  on 
the  tonsils  and  the  adenoid  tissue: 

Aluminis 0.65  (grs.  10) 

Acidi  tannici 0.65  (grs.  10) 

Glycerini    8.00  (drs.    2) 

Aquae 30.00  (oz.    i) 

Or 

lodi 0.13  (grs.    2) 

Potassii   iodidi — 0.65  (grs.  10) 

Glycerini 30.00  (oz.      i) 

Tonics  should  be  administered,  such  as  the  phos- 
phate of  iron  wine.  If  the  patient  is  no  better  for  the 
treatment,  and  the  symptoms  of  enlarged  tonsils  and 
adenoids  still  persist,  then  these  growths  should  be 
removed. 

ADENOMA 

This  tumor  originates  in  glandular  epithelium  and 
conforms  in  its  histologic  structure  with  glandular  tissue. 
When  there  is  an  excessive  development  of  the  connec- 
tive tissue  the  resultant  growth  is  called  an  adenofibroma. 
If  it  undergo  cancerous  degeneration  it  is  then  designated 
adenocarcinoma.  On  account  of  the  danger  of  this 
latter  change  the  tumors  should  be  removed  early,  par- 
ticularly if  they  show  a  tendency  to  grow  rapidly. 

AINHUM 

In  this  peculiar  disease,  practically  limited  to  the 
negro,  one  or  more  of  the  extremities  becomes  constricted 
and  undergoes  a  local  gangrene  and  even  spontaneous 
amputation.  The  gangrenous  spot  may  be  treated  simply 
by  protection  with  an  antiseptic  dressing  so  long  as  it 
remains  practically  quiescent,  providing  the  patient  will 
not  consent  to  amputation.  Later,  if  the  trouble  is  seen 
to  be  spreading  and  to  threaten  the  usefulness  of  the 


34  SURGICAL  THERAPEUTICS 

entire  limb,  one  or  more  incisions  may  be  made  through 
the  constricting  bands,  the  cut  being  made  parallel  to 
the  axis  of  the  limb;  or  the  fibrous  band  may  be  dissected 
out  in  its  entirety — one-half  being  cut  away  at  one  opera- 
tion, the  other  some  weeks  later  after  the  first  cut  has 
healed. 

AMEBIC  DYSENTERY 

i 
When  a  case  of  amebic  dysentery  is  doing  badly,  i.  e., 

when  there  is  a  reasonable  amount  of  strength  left 
but  internal  treatment  is  not  controlling  the  dysentery, 
there  should  be  no  delay  in  operating.  The  abdomen 
should  be  opened  as  for  appendicitis  (except  that  a  three- 
or  four-inch  cut  must  be  made),  the  cecum  drawn  up 
into  the  wound  and  sutured  to  the  parietes — the  appen- 
dix being  removed.  Next  day  the  cecum  should  be  widely 
opened  and  colonic  irrigation  with  strong  solutions  of 
quinine  instituted.  A  rapid  improvement  usually  follows 
the  beginning  of  irrigation,  but  convalescense  is  slow, 
and  at  times  difficulty  is  experienced  in  closing  the  fis- 
tula. The  after-treatment  (irrigation,  etc.)  is  tedious, 
and  the  patients  are  offensive  cases  to  have  in  hand;  it 
is  very  disagreeable  thus  to  treat  patients  in  hospital 
wards,  but  it  saves  lives  in  selected  cases. 

AMPUTATIONS 

Amputation  is  the  last  resort  of  the  true  surgeon. 
The  indications  are:  (i)  Complete  destruction  of  a 
part  of  an  extremity;  (2)  crushing  injuries  hi  which  the 
vitality  of  the  .part  beyond  the  site  of  trauma  is  inter- 
fered with  by  destruction  of  all  nutrient  vessels — the 
skin  sometimes  being  intact  yet  everything  inside  crushed 
to  a  jelly;  (3)  extensive  burns  where  it  is  evident  that  the 
extremity  even  if  saved  will  be  perfectly  useless;  (4)  exten- 
sive gangrene;  (5)  cancer  of  an  extremity.  Under  strict 


ANESTHESIA  35 

antisepsis  healing  by  primary  union,  without  a  drop  of 
pus,  should  be  obtained. 

ANAM  ULCER 

There  is  a  peculiar  ulcer  common  in  the  tropics  (first 
noted  in  Anam):  a  phagedena  which  begins  as  an  inflam- 
mation at  a  small  abrasion  of  the  skin,  most  often  on 
the  leg  or  foot,  soon  followed  by  deep  sloughing  of  the 
inflamed  area — resulting  in  a  sharp-cut  ulcer  which  slowly 
enlarges,  always  preceded  by  the  inflammation.  It  very 
obstinately  resists  treatment. 

Fluidextract    of    lobelia 32.0  (i  ounce) 

Fluidextract  of  baptisia 32.0  (i  ounce) 

Sulphate  of  zinc 32.0  (i  ounce) 

Water 500.0  (i  pint) 

Of  this  mixture  one  ounce  to  the  pint  of  hot  water 
is  used  in  a  douche-bag,  carefully  irrigating  once  daily. 
Dress  with  gauze  saturated  with  a  mixture  of  camphor 
and  phenol,  equal  parts.  Internally  iodides  or  mercury 
— the  trouble  often  being  of  syphilitic  origin. 

ANESTHESIA 

Cocaine  and  Brucine. — The  Abbott  Alkaloidal  Com- 
pany has  prepared  a  most  excellent  mixture  of  cocaine  and 
brucine  for  local  anesthesia,  possessing  distinct  advantages 
over  cocaine  alone. 

Cocaine  by  Cataphoresis. — Some  patients  object 
strenuously  to  the  use  of  the  hypodermic  syringe.  When 
it  is  desired  to  operate  under  cocaine  anesthesia  upon 
such  a  "crank,"  the  cocaine  may  be  introduced  by  cata- 
phoresis.  A  piece  of  gauze  is  folded  to  four  thicknesses 
and  cut  the  size  of  the  part  to  be  analgesized;  the  skin, 
sterilized,  is  covered  with  this  gauze  saturated  in  cocaine 
solution  of  the  strength  of  10  percent,  i.  e.,  about  45 
grains  to  the  ounce  of  water;  this  is  covered  with  lead- 


36  SURGICAL  THERAPEUTICS 

foil  cut  the  same  size;  then  the  positive  pole  of  a  galvanic 
battery  is  applied  to  this — the  patient  holding  the  wet 
sponge  electrode  of  the  negative  pole  in  his  hand.  A 
battery  of  twenty  or  thirty  cells  is  necessary,  and  the  cur- 
rent used  as  strong  as  the  patient  can  stand  it.  From 
fifteen  to  thirty  minutes  is  required  for  deep  cocainiza- 
tion;  the  gauze  being  resaturated  about  every  five  minutes, 
it  being  poured  under  the  foil  by  raising  the  edges  first 
on  one  side  and  then  the  other,  thus  not  breaking  the  cur- 
rent. If  desired,  one  dram  of  i  in  1000  solution  of  adre- 
nalin solution  may  be  added  to  the  ounce  of  cocaine  solu- 
tion, to  prevent  bleeding  from  the  part  to  be  incised;  the 
only  objection  being  that  oozing  is  apt  to  occur  an  hour 
or  so  after  the  suturing  is  completed  and  the  wound  dressed. 

Cocaine  Hypodermically. — Either  a  2-percent  or  a 
4-percent  solution  may  be  used.  A  half-grain  tablet  dis- 
solved in  a  full  hypodermic  of  water  (25  minims)  give  a 
4-percent  solution.  More  than  one  such  injection  should 
rarely  be  used.  If  more  is  required,  on  account  of  the 
large  area  to  be  cut,  it  is  better  to  dilute  to  a  2-percent 
solution. 

In  about  one  case  in  ten  some  symptoms  of  poisoning 
will  follow  the  injection  of  cocaine  for  surgical  purposes. 
Ordinarily  the  patient  will  merely  complain  of  a  little  faint- 
ness,  and  dilation  of  pupils  occurs.  But,  rarely,  especially 
when  only  a  2-percent  solution  has  been  injected  into  the 
tongue,  alarming  symptoms  arise:  faintness  even  to  com- 
plete syncope,  nausea,  and  vomiting,  temporary  blindness 
with  excessive  mydriasis,  coldness  and  clamminess  of  the 
skin,  with  almost  imperceptible  pulse;  even  epileptiform 
convulsions  have  been  reported.  But  no  death  will  follow! 
So  the  proper  treatment  is  to  give  the  patient  a  "good 
drink"  of  whisky,  place  him  in  the  recumbent  position  and 
go  on  with  the.  operative  work.  By  the  time  the  operation 
is  finished  most  of  the  unpleasant  symptoms  will  have 


ANESTHESIA  37 

disappeared;  and  in  an  hour  or  so  the  patient  will  be  as 
well  as  ever. 

Cocaine  on  Mucous  Membranes, — Cocaine  applied 
to  the  surface  of  the  mucous  membrane  of  the  mouth, 
throat,  urethra  and  nose  gives  a  perfect  surgical  analgesia; 
but  on  the  perpuce  and  glans  and  in  the  rectum  and  vagina 
it  will  not  do  so,  hence  in  operating  upon  any  of  these 
parts  the  cocaine  must  be  injected  into  the  submucous 
cellular  tissue.  Operation  is  usually  begun  too  soon 
after  injection — at  least  two  full  minutes  should  pass 
before  the  mucous  membrane  is  cut.  The  analgesia  per- 
sists from  twenty  minutes  to  a  half  hour. 

"Combined"  Anesthetics,  [A.  C.  E.  Mixture].— 
The  A.  C.  E.  mixture  was  formerlv  much  employed.  It 
consists  of 

Alcohol   i    part 

Chloroform 2  parts 

Ether 3  parts 

It  has  been  almost  abandoned  since  the  discovery 
that  its  use  results  in  practically  a  straight  chloroform- 
anesthesia. 

Ether  by  the  Drop  Method, — Recently  it  has  been 
demonstrated  that  ether  may  be  given  in  the  same  way 
that  modern  men  have  given  chloroform:  with  a  dropper 
and  an  Esmarch  mask.  The  ether  is  poured  on  much 
more  freely  than  the  chloroform,  is  kept  constantly  drop- 
ping (no  setting  down  of  the  bottle  under  any  circum- 
stances) and  is  varied  from  one  part  of  the  mask  to  the 
other  so  that  none  shall  run  through.  It  requires  fully 
fifteen  minutes  to  secure  complete  surgical  anesthesia, 
but  the  effect  is  much  more  satisfactory  than  from  any 
other  method  thus  far  devised.  Instead  of  the  wild  fight- 
ing of  the  old  "suffocation"  mode  of  administration  the 
patient  sinks  tranquilly  into  unconsciousness;  instead 
of  a  pound  or  two  of  ether  being  used  a  few  ounces  suf- 


38  SURGICAL  THERAPEUTICS 

fice;  instead  of  the  intense  nausea  and  vomiting  of  the  old 
way  there  is  but  slight  stomachic  disturbance,  since  very 
little  of  the  ether  is  swallowed  to  irritate  the  gastric  mucous 
membrane. 

Ethyl  Chloride. — This  anesthetic  is  now  being  pro- 
duced so  cheaply  that  it  bids  fair  to  become  extremely 
popular  for  minor  surgery.  In  the  peculiar  bottles  in 
which  it  comes  it  is  volatilized  by  the  heat  of  one's  hand 
so  that  when  the  lever  is  pressed,  which  opens  a  tiny  hole 
in  the  stopper,  a  fine  spray  is  produced,  scarcely  visible. 
As  the  ethyl  chloride  boils  at  13°  C.,  an  intense  cold  is  pro- 
duced by  the  rapid  evaporation — to  such  a  degree  that 
the  skin  against  which  it  is  directed  for  one  minute  is 
frozen  and  in  a  few  seconds  more  is  covered  by  a  fine  frost. 
A  surface  a  half  inch  wide  and  as  much  as  two  inches 
long  may  be  frozen  readily  by  rapidly  moving  the  spray 
up  and  down  the  length  of  the  proposed  incision.  The 
tip  of  the  injector  should  be  held  from  three  to  five  inches 
away  from  the  skin  to  get  the  best  spray.  Incision  may 
be  made  through  the  frost  or  one  may  wait  until  it  is 
melted;  the  analgesia  lasting  about  two  minutes. 

It  is  ideal  for  opening  abscesses,  removing  small  tumors 
or  for  the  use  of  the  Paquelin  cautery  on  small  epithelial 
growths.  Recently  it  has  been  used  by  inhalation  as 
a  substitute  for  ether,  the  anesthesia  being  produced 
more  quickly,  thus  saving  an  average  of  some  twelve 
minutes  on  each  operation;  hence  it  is  likely  to  prove  use- 
ful on  the  battlefield  and  in  other  calamities  when  a  num- 
ber of  operations  must  be  performed  rapidly,  one  after 
another.  Its  chief  danger  seems  to  be  the  production  of 
pneumonia  from  cold  vapor. 

How  to  Give  Chloroform.. — So  few  doctors,  even 
recent  graduates  who  have  served  as  internes  in  the  great 
hospitals,  know  how  to  give  chloroform  properly  (i.  e., 
safely),  that  the  following  should  be  read  at  least  twice 


ANESTHESIA  39 

by  every  doctor;  and  once  again  by  him  who  thinks  he 
knows  how!  It  is  the  method  which  has  proven  safest 
as  demonstrated  in  many  thousands  of  anesthesias;  viola- 
tion of  the  rules  is  what  leads  to  the  occasional  death 
of  a  patient. 

There  are  four  chief  things  to  be  constantly  borne 
in  mind  by  the  anesthetist: 

1.  To  watch  the  patient,  not  the  operator. 

2.  To  keep  an  eagle  eye  upon  the  respiration;  the 
pulse  is  of  only  secondary  importance. 

3.  To     begin     administration     quietly    and    slowly; 
more  than  ninety  percent  of  all  deaths  occur  during  the 
first  few  inhalations  of  the  vapor. 

4.  To   carry  the  patient   quickly  to  profound  anes- 
thesia, and  then  keep  him  unconscious  with  the  slightest 
possible  amount  of  chloroform. 

Apparatus  to  be  Used 

The  only  safe  way  to  give  chloroform  is  by  means  of 
a  dropper  and  an  Esmarch  inhaler,  or  some  modification 
of  the  same. 

a.  The  Bottle. — Any  bottle  will  do  which  has  a  mouth 
small  enough  to  fit  the  cork;  but  it  should  never  be  more 
than  half  full  at  the  time  of  using.     The  loo-gram  bottle 
in  which  chloroform  now  is  sold  is  the  best. 

b.  The  Dropper. — With  the  regular  Esmarch  appar- 
atus there  comes  a  cork  with  metal  dropper. 

There  are  two  objections  to  this  dropper:  (i)  It 
allows  chloroform  to  escape  too  freely,  particularly  at  a 
moment  when  but  little  is  desired,  and  (2)  often  it  is  not 
at  hand  when  wanted. 

A  far  more  satisfactory  dropper  can  be  manufactured 
at  the  bedside  in  two  minutes  with  a  sharp  knife,  a  cork 
and  a  little  bit  of  cotton.  A  cork  which  fits  the  neck  of 
the  bottle  to  be  used  is  grooved  from  end  to  end  on  two 


40  SURGICAL  THERAPEUTICS 

sides,  the  groove  being  made  less  than  a  sixteenth  of  an 
inch  deep;  a  little  of  the  cotton  is  laid  in  one  groove  so 
that  it  extends  beyond  each  end  of  the  cork,  and  the  cork 
and  cotton  are  inserted  snugly  in  the  bottle  half  filled 


Fig.  1.     Dropper  made  from  common  bottle 
^  with  cork  and  cotton 

with  chloroform.  When  turned  from  the  upright  to  the 
horizontal,  this  dropper  will  give  down  chloroform  in 
minute  drops,  about  one-fourth  the  size  of  those  from 
the  Esmarch. 

c.     The  Mask. — Two  thicknesses  of  gauze  stretched 
over  a  wire  frame  constitute  the  receiver  of  the  chloroform. 


Fig.  2.     Cork  cut  to  make  a  dropper 

It  must  not  be  permitted  to  touch  the  face  until  the  patient 
is  profoundly  asleep;  then  it  may  be  allowed  to  rest  gently 
over  the  nose  and  mouth. 

Cotton  should  never  be  put  in  the  concavity  of  this 
mask,  nor  should  more  than  four  thicknesses  of  gauze 
be  used — patients  must  have  at  least  95  percent  of  air 
(i.  e.,  never  more  than  5  percent  of  chloroform  vapor) 
at  any  stage  of. an  anesthesia. 


ANESTHESIA  41 

When  a  mask  is  not  at  hand,  one  may    be  improvised 
very  effectively  by  taking  a  towel,   stiff  with  starch,   if 


Fig.  3.     Patent  drop-bottle 

possible,  and  making  a  cup-shaped  "pucker"  in  one  side 
of  it,  as  shown  in  the  cut. 

This  may  be  placed  over  the  patient's  mouth  and 
nose  and  the  chloroform  dropped  upon  it. 

Method  0}  Administration 

The  patient  being  in  the  position  desired  for  opera- 
tion is  told  to  close  the  eyes  and  go  quietly  to  sleep.  He 
should  never  be  told  to  breathe  deeply.  Nor  should  he  be 


Fig.  4.     Esmarch  inhaler 

requested  to  count — both  tend  to  excite  the  patient's 
fears  and  disturb  his  tranquillity.  The  only  directions 
should  be:  "Try  to  go  to  sleep,"  "keep  your  eyes  closed," 
and  "don't  mind  the  smell  at  the  beginning."  Especial 
care  should  te  used  not  to  say,  "Don't  mind  the  smother- 
ing sensation" — that  is  sure  to  cause  anxiety;  and  it  is 
fear  which  kills  at  the  beginning  of  anesthesia.  The 
eyes  should  be  covered  by  a  towel. 


42 


SURGICAL  THERAPEUTICS 


The  mask  being  placed  over  the  nose,  two  or  three 
inspirations  should  be  permitted  without  any  chloroform; 
then  a  single  drop — or  two,  never  more — is  allowed  to 
fall  on  the  top  of  the  mask  and  the  patient  asked  pleas- 
antly if  he  likes  the  smell,  with  the  assurance  that  the  chloro- 
form will  not  be  given  too  strong.  After  two  or  three 
inhalations  of  this  very  mild  vapor,  five  or  ten  drops  are 
to  be  poured  on  and  the  mask  slowly  lowered  to  within 
a  half  inch  of  the  face;  when  the  patient  has  breathed 
this  stronger  vapor,  three  or  four  times  the  amount  may  be 
quite  rapidly  increased,  so  that  within  two  minutes  after 


Fig.  5.     Emergency  mask 

beginning  the  anesthesia  its  administration  should  be 
under  full  headway  if  the  patient  behave  properly;  if  he 
be  excitable,  a  little  longer  may  be  required.  At  the  end 
of  two  or  three  minutes  the  rate  of  dropping  should  be 
about  two  per  second,  the  drops  being  made  to  fall  in  a 
circle  near  the  margin  of  the  mask.  There  should  be  no 
intermission  in  this  dropping  (if  the  patient  be  breathing 
regularly  and  easily)  until  the  patient  is  fully  under  the 
influence.  The  man  who  stops  ^o  set  the  bottle  down 
on  the  table,  before  the  patient  is  unconscious,  is  a  dan- 


ANESTHESIA  43 

gerous  anesthetist — the  only  exception  being  when  the 
patient  does  not  breathe  well. 

At  a  certain  point  in  the  process  of  anesthetization 
(where  the  " stage  of  excitement"  is  said  to  begin)  the 
patient  is  very  apt  to  hold  his  breath,  and  the  inexper- 
ienced anesthetist  becomes  uneasy  or  even  alarmed;  but 
all  that  is  necessary  to  do  is  to  remove  the  mask,  gently 
press  on  the  lower  end  of  the  sternum,  with  the  sharp 
command,  "Go  on  breathing,"  and  allow  two  or  three 
breaths  of  air;  then  as  soon  as  respiration  is  regular  go 
on  with  the  dropping.  If  any  time  is  lost  at  this  point 
the  patient  may  become  very  much  excited  (especially 
if  addicted  to  alcohol),  but  if  just  enough  chloroform  be 
given,  the  "stage  of  excitement"  may  usually  be  entirely 
avoided. 

After  a  few  more  breaths  the  patient  may  try  to  vomit, 
but  unless  something  actually  comes  up  into  the  throat 
(in  which  case  the  latter  must  be  quickly  cleaned  out) 
no  attention  need  be  paid  to  this,  as  a  few  more  drops  of 
chloroform  will  put  a  stop  to  it. 

In  three  minutes  a  quiet  patient  should  be  put  into 
perfect  surgical  anesthesia;  an  excitable  one  inside  of 
five.  The  doctor  who  requires  ten  to  fifteen  minutes  to 
chloroform  a  patient  is  not  a  safe  anesthetist. 

As  soon  as  the  operation  is  begun  the  amount  oi  chloro- 
form may  be  diminished;  the  pulse  examined,  so  determin- 
ing that  the  heart  is  right;  and  the  pupil  looked  at  to  see 
if  it  be  properly  contracted.  At  an  early  stage  of  chloro- 
form inhalation  the  pupil  becomes  dilated  for  a  minute 
or  two,  but  as  soon  as  anesthesia  is  complete  it  is  con- 
tracted slightly  beyond  normal  and  should  remain  so  to 
the  end;  secondary  dilation  means  too  much  chloroform 
— so  the  pupil  should  be  frequently  inspected  during 
the  later  stages  of  the  work.  But  no  man  should  stick  his 
finger  in  the  eye  to  see  if  the  conjunctival  reflex  is  abolished. 


44  SURGICAL  THERAPEUTICS 

During  the  progress  of  the  work  from  five  to  twenty 
drops  per  minute  will  be  required  to  keep  the  patient 
asleep.  As  there  are  rather  more  than  120  drops  to  the 
fluid  dram,  about  one  ounce  should  suffice  for  a  full  hour's 
profound  anesthesia;  and  some  patients  require  less  than 
half  this  amount;  if  two  doses  of  hyoscine-morphine- 
cactin  compound  have  been  given  before  operation,  one 
dram  will  be  an  abundance.  Just  enough  should  be  used 
to  keep  the  patient  from  moving;  he  should  never  be  per- 
mitted to  wake  up  enough  to  feel  the  pain. 

Accidents:    How  to  Handle  Them 

1.  The  most   common  accident  is  "swallowing  the 
tongue."    When  this  occurs  (always  after  complete  anes- 
thesia), bottle  and  mask  must  be  laid  aside  and  the  chin 
of  the  patient  raised  by  placing  a  thumb  on  each  side  of 
the  face  above  the  angle  of  the  jaw  and  three  fingers  on 
the  neck  below  the  angle,  when  by  pulling  upward  and 
forward  the  larynx  will  be  straightened  and  the  tongue 
drawn  forward  out  of  the  pharynx.     The  man  who  wants 
to  use  a  tongue-forceps  is  one  never  worthy  of  trust  as  an 
anesthetist.     In    extreme    cases    a    finger    wrapped    with 
gauze  may  have  to  be  inserted  into  the  throat  to  unroll 
the  tongue;  but  it  should  not  be  once  in  a  thousand  cases; 
in  all  others  elevation  of  the  jaw  is  all  that  is  required. 

2.  Cessation  of  respiration  is  the  most  dangerous  of 
all  accidents.     If  too  much  chloroform  be  given,  the  patient 
turns  livid  (from  imperfect  oxidization  of  the  blood)  and 
finally   he   ceases   breathing.     Artificial   respiration   must 
at  once  be  instituted,  and  if  voluntary  respiration  is  not 
begun  within  two  or  three  minutes,  the  head  should  be 
lowered  and  the  angle  "of  the  jaw  raised  again  while  arti- 
ficial breathing  is  continued.     Usually  respiration  will  be 
restored  in  a  minute  or  two,  though  sometimes  ten  to  twenty 
are  required;  and  as  much  as  forty  have  been  required  in 


ANESTHESIA  45 

extreme  cases.  So  in  fatal  cases  not  less  than  an  hour's 
work  is  permissible.  As  soon  as  respirations  are  regular 
and  the  color  is  good  a  small  amount  of  chloroform  may 
be  given,  but  usually  only  a  little  will  be  required. 

3.  Vomiting  is  sometimes  troublesome  if  the  patient 
has   eaten   within   eight   hours   of  the  operation.     When 
the  stomach-contents  come  up  into  the  throat  the  head 
should  be  turned  to  one  side  to  permit  ejection,  and  the 
chloroform  stopped  for  a  moment  until  the  throat  can 
be  cleared.     A  piece  of  gauze  or  corner  of  a  soft  towel 
may  be  used  to  wipe  out  the  mouth  and  even  the  pharynx 
when  necessary.     As  soon  as  two  or  three  full  breaths 
have    been    taken   by   the   patient,    dropping   should   be 
resumed. 

4.  Heart-failure  is  an  accident  not  likely  to  occur  if 
the   respiration    continues    good,  unless    there    has    been 
excessive  loss  of  blood  or  prolonged  exposure  of  viscera. 
When  the  pulse  becomes    weak  or    wavers  greatly  an 
injection  of  a  pint  of  normal  salt  solution  (a  teaspoonful 
of  salt  to  the  quart  of  water,  boiled  and  allowed  to  cool) 
should  be  made  into  each  breast  or  each  buttock.     While 
this  is  being  done,  i-ioo  grain  of  glonoin  (nitroglycerin) 
should  be  injected  in  the  arm  or  neck;  or  if  death  seems 
dangerously  near,  three  or  four  syringefuls  of  ether  may 
be    injected — but   never   unless   the    situation    is   urgent. 
The   salt   solution  does  best.     Of  course   the   anesthetic 
is  to  be  discontinued  during  these  manipulations. 

How  to  Give  Ether. — A  piece  of  rubber-tissue  is 
placed  over  the  patient's  eyes;  or  in  its  absence  a  few  lay- 
ers of  moist  gauze  may  be  used,  to  shield  the  eyes  from 
the  irritating  vapor  of  ether.  Over  this  a  moist  towel 
is  laid  and  wrapped  carefully  around  the  chin  and  head 
in  such  way  that  only  the  nose  is  exposed. 

Preferably  the  apparatus  used  is  a  wire  frame  very 
much  like  the  Esmarch  chloroform  inhaler,  made  larger  in 


46  SURGICAL  THERAPEUTICS 

order  to  give  more  space  under  the  inhaler  for  the  mixture 
of  air  and  ether;  and  the  outline  of  the  mask  curved  to 
fit  the  face  closely.  If  this  special  mask  is  not  at  hand  the 
regular  chloroform-inhaler  mask  will  do.  The  wire  frame 
should  be  covered  with  one  or  two  layers  of  stockinette 
or  gauze.  The  air  space  under  the  frame  must  contain 
about  25  cubic  inches,  that  is,  about  three  times  more  than 
the  ordinary  Esmarch's  inhaler.  The  best  covering  is 
about  six  layers  of  gauze,  which  can  be  quickly  applied 
and  thrown  away  after  being  used.  The  wire  frame  should 
be  boiled  immediately  after  use.  When  everything  is  ready 
for  beginning  anesthesia  the  mask  is  laid  over  the  patient's 
nose  and  a  few  drops  of  ether  allowed  to  flow  on  it.  The 
patient  usually  complains  of  the  smell  or  jerks  the  head 
from  side  to  side,  but  this  nervousness  disappears  in  a 
moment  or  two  if  assurance  is  given  in  a  firm  tone  that 
everything  is  all  right  and  that  the  bad  smell  will  pass 
away.  At  first  the  dropping  must  be  very  slow;  then  as 
the  patient  becomes  accustomed  to  the  vapor  the  amount 
is  rapidly  increased  until  a  very  fine  stream  is  being  pro- 
jected constantly  through  the  "dropper"  in  the  can,  the 
same  dropper  being  used  that  is  made  for  chloroform. 

As  soon  as  sleep  is  so  deep  that  the  patient  will  not 
respond  to  questions  a  moist  towel  or  gauze  should  be 
wrapped  snugly  around  the  mask,  leaving  a  small  area  in 
the  center  for  the  free  passage  of  air  through  the  gauze. 
By  this  method  the  air  is  prevented  from  escaping  around 
the  edges  of  the  mask  and  is  made  to  pass  through  the 
ether-laden  gauze. 

The  ether  should  not  be  at  any  time  dropped  on  faster 
than  the  patient  can  comfortably  breathe  it  in. 

Patients  should  preferably  be  anesthetized  on  the  oper- 
ating-table. Such  as  "are  too  nervous  to  be  taken  to  the 
operating-room  can  be  put  on  the  carriage  in  the  anesthe- 
tizing-room  and  rolled  into  the  operating-room  after  the 


ANESTHESIA  47 

anesthetic  has  taken  effect.  The  anesthetizing-room  should 
be  kept  absolutely  quiet,  because  all  sounds  are  very  much 
magnified  to  a  patient  who  is  about  to  pass  into  the  second 
stage  of.  anesthesia. 

Above  all  things,  the  anesthetist  should  not  let  an  im- 
patient operator  worry  or  hurry  him  on,  but  remember 
that  the  welfare  of  the  patient  depends  upon  the  slow 
and  gradual  ratio  of  the  increasing  concentration  of  the 
ether-vapor. 

The  patient  will  become  unconscious  in  two  or  three 
minutes  and  should  be  ready  for  the  operator  in  about 
ten  minutes. 

When  a  patient  has  become  thoroughly  anesthetized 
very  little  ether  dropped  slowly  but  continually  will  suffice 
to  maintain  the  proper  condition. 

Hyoscine-Morphine-Cactin  Compound. — In  view 
of  the  facts:  (i)  that  there  is  at  present  a  most 
lively  interest  in  hypodermic  anesthesia;  (2)  that  it 
seems  demonstrable  that  a  perfect  surgical  anesthesia 
may  be  produced  safely  by  a  certain  combination  con- 
taining chemically  pure  hyoscine;  (3)  that  an  impure 
"  scopolamine "  upon  the  market  produces  death  or  very 
alarming  symptoms,  and  (4)  that  certain  pharmacolo- 
gists are  claiming  that  scopolamine  and  hyoscine  are 
identical  and  that  the  socalled  "  Abbott-Lanphear  anes- 
thesia" is  therefore  dangerous,  it  seems  to  me  that  a  care- 
ful analysis  of  the  facts,  together  with  a  few  words  of 
warning,  should  be  of  interest  to  the  profession. 

The  following  are  the  chief  points  of  import: 

1.  That  "scopolamine"  made  from  scopola  atropoides 
is  an  unreliable  and  sometimes  dangerous  drug. 

2.  That  "hyoscine"  made  from  henbane  is  not,  thera- 
peutically,  identical  with  the  "scopolamine"  of  commerce, 
even  though  it  be  named  "hyoscine,"  as  much  of  the"  com- 
mercial scopola-derived  drug  is. 


48  SURGICAL  THERAPEUTICS 

3.  That  a  proper  mixture  of  chemically  pure  (true) 
hyoscine,  morphine  and  cactin  is  a  safe,  cheap  and  efficient 
substitute  for  chloroform  and  ether  for  surgical  anesthesia 
and  for  painless  confinement;  and  as  an  analgesic  is  far 
superior  to  the  usual  morphine-atropine  combination. 

i.  "Relative  to  the  first  proposition  I  said  in  my  first 
contribution  to  the  literature  of  this  subject  that  the  scopo- 
lamine  used  by  some  manufacturers  of  hypodermic  tablets 
is  (i)  often  unreliable  and  (2)  sometimes  dangerous — that 
"fifteen  or  more  deaths  have  been  reported  from  its  use—- 
and hence  it  has  been  abandoned  by  most  operators; 
besides  its  danger,  it  has  been  found  to  be  unreliable, 
Merck  saying  that  only  scopolamine  of  -20°  optical  rota- 
tion is  safe  and  serviceable,  while  much  in  the  market  is  as 
low  as  -2°,  being  practically  valueless."  ^  And  W.  C.  Ab- 
bott, of  Chicago,  in  The  International  Journal  of  Surgery, 
February,  1906,  pointed  out  the  same  thing. 

H.  C.  Wood,  Jr.,  of  Philadelphia,  analyzed  the  reported 
fatalities  (mostly  foreign)  from  the  use  of  commercial 
scopolamine  and  morphine,  and  in  an  article  in  American 
Medicine,  December,  1906,  concludes  that  of  the  deaths 
recorded  at  least  nine  were  directly  traceable  to  the  scopo- 
lamine-morphine  used  to  induce  anesthesia. 

But  his  assertion  that  therefore  only  ignorant  surgeons 
will  continue  to  use  a  hyoscine-morphine  combination  to 
produce  surgical  anesthesia  is  based  upon  his  assumption 
that  scopolamine  (or  socalled  "hyoscine")  made  from 
scopola  atropoides  is  identical  with  hyoscine  prepared  from 
hyoscyamus  niger,  because  certain  manufacturers  so  de- 
clare and  the  United  States  Pharmacopeia  states  that 
hyoscine  and  (pure)  scopolamine  have  the  same  chemical 
formula. 

I  believe  all  investigators  agree  that  scopolamine  as 
found  in  the  market  is  usually  unreliable  and  sometimes, 
in  fact  often,  dangerous. 


ANESTHESIA  49 

2.  To  substantiate,  if  possible,  that  which  I  felt  sure 
I  had  clearly  demonstrated,  experimentally:  that  chemically 
pure  hyoscine  made  from  henbane  is  not,  therapeutically 
— and  possibly  not  chemically — the  same  as  scopolamine 
(or  socalled  "hyoscine"  from  scopola),  I  wrote  to  the 
leading  manufacturers  of  hypodermic  tablets  in  the  United 
States,  submitting  certain  questions  for  answer.  As  a 
result  of  this  correspondence  it  may  be  said: 

(a)  That  much  of  the  "scopolamine"  bought  by  cer- 
tain commercial  manufacturers  is  impure,  of  low  rotatory 
power,  and  unreliable; 

(b)  That  some  of  the  "  scopolamine  "  is  dangerous  from 
admixture  with  apoatropine; 

(c}  That  some  "hyoscine"  tablets  are  simply  "scopo- 
lamine"— which  may  or  may  not  be  dangerous  on  the  one 
hand  or  unreliable  on  the  other; 

(d)  That  there  is  obtainable  a  chemically  pure  hyos- 
cine made  from  hyoscyamus,  of  not  less  than  -20°  optical 
rotation,  free  from  apoatropine,  atroscine,  etc.;  and 

(e)  That   this   hyoscine   differs   therapeutically   from 
most  of  the  "scopolamine"  sold  in  this  country,  the  former 
being  perfectly  reliable  and  apparently  safe. 

Directly  bearing  upon  this  second  proposition  is  the 
following  from  a  letter  written  by  Messrs.  Merck  &  Co.: 
"Hyoscine  hydrobromide  and  scopolamine  hydrobromide 
are  identical,  that  is,  the  absolutely  pure  alkaloids  are  iden- 
tical; but  impurities  vary,  naturally,  as  the  two  are  made 
from  two  different  plants — though  there  should  be  no  im- 
purities if  they  are  properly  prepared.  Chemically  pure 
scopolamine  is  a  safe  remedy  in  doses  of  i-ioo  grain,  and 
is  therapeutically  active  if  close  to  -20°.  There  are, 
however,  inferior  products  on  the  market;  the  most  impor- 
tant one  of  these  as  to  sales  [italics  mine]  has  a  rotatory 
power  of  only  -2°.  Such  a  oroduct  must  contain  impuri- 
ties, such  as  atroscine." 


50  SURGICAL  THERAPEUTICS 

John  Wyeth  &  Bro.  write:  "Mr.  Louis  Merck,  of 
the  firm  of  Merck  &  Co.,  Darmstadt,  Germany,  the  lead- 
ing manufacturers  of  alkaloidal  salts,  states  in  a  paper 
published  in  The  American  Journal  of  Pharmacy  that  the 
hyoscine  put  upon  the  market  by  his  firm  has  been  and  is 
identical  in  chemical  formula  with  scopolamine,  but  the 
firm  retains  the  name  hyoscine  for  the  alkaloid  from  hyos- 
cyamus,  and  scopolamine  for  the  alkaloid  from  Scopola 
atropoides. 

"Nevertheless,  despite  this  apparent  identity,  it  seems  to 
be  pretty  safely  established  that  these  two  substances  differ 
materially  in  their  therapeutic  action.  This  is  no  doubt 
due  to  the  fact  that  the  commercial  scopolamine  hydro- 
bromide  contains,  as  a  rule,  a  varying  admixture  of  an- 
other scopola  alkaloid.  Owing  to  the  presence  of  this 
alkaloid,  commercial  scopolamine  has,  as  a  rule,  a  much 
lower  rotatory  power  than  the  salt  prepared  from  henbane 
(hyoscyamus  niger) ;  and  Schmidt  concludes,  from  the  fact, 
since  scopolamine  may  be  obtained  with  normal  or  with 
feeble  rotatory  power,  according  to  the  mode  of  operating 
on  scopola,  that  the  inactive  scopolamine  does  not  exist 
naturally  in  the  root  but  is  formed  in  the  course  of  ex- 
traction. The  admixture  of  varying  proportions  of  atro- 
scine  in  commercial  scopolamine  is  evidenced  by  the  vary- 
ing melting  point  of  the  latter,  which  ranges  all  the  way 
from  178°  to  i9o°C. 

"We  answer  your  specific  questions  as  follows:  (i) 
Is  hyoscine  hydrobromide  therapeutically  the  same  as  scopo- 
lamine? Answer:  No.  (2)  Is  the  optical  rotation  of 
hyoscine  variable  from  -20°  to  -2°,  as  is  scopolamine? 
Answer:  No.  (3)  Is  commercial  scopolamine  a  safe 
remedy  in  doses  of  i-ioo  grain  or  does  it  contain  atroscine, 
apoatropine  or  other  impurities  which  rerider  it  dangerous  ? 
Answer:  Not  as  safe  as  hyoscine,  owing  to  the  varying 
proportion  of  atroscine,  etc.,  present.  (4)  Does  hyoscine 


ANESTHESIA  51 

hydrobromide  as  employed  by  you  for  making  hypodermic 
tablets  contain  any  impurities  which  make  it  a  dangerous 
remedy  in  doses  of  i-ioo  grain,  every  hour,  three  times? 
Answer:  We  have  been  using  for  years  hyoscine  hydro- 
bromide  made  by  one  of  the  most  reliable  manufacturers 
in  the  world,'  and  despite  the  fact  that  we  have  been  sel- 
ling these  tablets  in  large  quantities  for  a  good  many  years, 
we  have  never  had  any  complaint  of  their  causing  any 
untoward  effects." 

Upon  this  question  Sharp  &  Dohme  write  interest- 
ingly: "There  are  two  kinds  of  this  product  (scopolamine) 
upon  the  market,  one  optically  active,  with  an  optical 
rotation  to  the  left  varying  from  -20  to  -2  degrees,  and  the 
other  optically  inactive.  The  melting  point  of  these  two 
is  different,  the  inactive  melting  at  179.7%).  and  the  active 
melting  at  i9i.6°C.  The  optically  active  preparation  is 
the  preferable  one,  although  the  manufacturers  of  the 
other  claim  that  both  are  equally  efficient  therapeutically. 
But  Kobert  has  shown  that  apoatropine  sometimes  is  pres- 
ent, and  when  it  is  so, -the  optical  rotation  is  greatly  re- 
duced; and  apoatropine  is  responsible  for  the  bad  after- 
effects. If  it  is  levorotatory  less  than  10  degrees  it  would 
indicate  that  it  is  mixed  with  some  apoatropine.  We  use, 
in  making  our  hypodermic  tablets,  a  hyoscine  hydrobromide 
in  which  the  alkaloid  possesses  a  distinct  levorotatory  ac- 
tion upon  polarized  light  only." 

Eli  Lilly  &  Co.  write  practically  in  substantiation  of 
these  facts,  as  do  also  G.  F.  Harvey  &  Co.,  and  Nelson, 
Baker  &  Co.  (who,  however,  state  that  they  supply  the 
alkaloid  of  scopola — scopolamine — whenever  hyoscine  is 
ordered,  but  so  inform  the  purchaser).  Mallinckrodt 
Chemical  Works  make  their  "hyoscine"  as  well  as  "scopo- 
lamine" from  scopola — in  which  they  are  fortified  by  per- 
mission of  the  U.  S.  P.  John  T.  Milliken  &  Co.  declined 
to  answer.  Parke,  Davis  &  Co.  ignored  the  request  for 


52  SURGICAL  THERAPEUTICS 

information,  simply  referring  me  to  the  misleading  and 
wholly  unreliable  matter  in  The  Journal  of  the  American 
Medical  Association. 

The  Abbott  Alkaloidal  Company  use  only  chemically 
pure  hyoscine  derived  from  hyoscyamus,  -20  degrees  rota- 
tion, and  label  the  tablets  made  from  the  alkaloid  of 
scopola  ' '  scopolamine . ' ' 

Dr.  Abbott's  position  is  well  known:  that  only  pure 
hyoscine  hydrobromide  should  be  employed  for  making 
this  anesthetic  tablet;  and  that  if  scopolamine  be  substi- 
tuted, it  should  be  with  a  full  understanding  that  by  rea- 
son of  one  impurity  or  another  it  may  be  either  unreliable 
or  dangerous — a  danger  for  which  the  surgeon  himself 
must  be  held  responsible,  since  he  can  easily  secure  pure 
hyoscine  instead. 

3.  As  to  the  third  proposition,  there  is  much  to  be 
said.  After  exhaustive  experimentation  the  formula  de- 
cided upon  by  Dr.  Abbott  and  adopted  and  extensively 
used  by  myself  is: 

Chemically  pure  hyoscine  hydrobromide,  i-ioo  grain. 

Chemically  pure  morphine  hydrobromide,  1-4  grain. 

Cactin  (from  cactus  grandiflorus),  1-67  grain. 

Dosage. — For  small  operations,  like  repair  of  lacer- 
ated cervix,  appendectomy,  removal  of  gallstones,  resection 
of  the  bowel,  etc.:  one  tablet  to  be  injected  into  the 
arm  two  hours  before  operation;  a  second,  a  half  hour 
before  operation;  twenty  to  forty  drops  of  chloroform  at 
beginning  of  operation  or  a  little  cocaine  locally. 

For  huge  operations,  like  abdominal  hysterectomy, 
trephining,  Kraske  operation,  amputation  of  thigh,  etc.: 
one  tablet  hypodermically  three  hours  before  operation; 
a  second  an  hour  and  a  half  later,  and  a  third  when  the 
patient  is  put  upon  the  table.  By  the  time  preparations 
are  completed,  hypnotic  anesthesia  usually  will  be  pro- 
found. Robust  male  patients  may  require  a  few  drops  of 


ANESTHESIA  53 

chloroform  by  inhalation — from  one-half  to  one  dram 
sufficing  for  three  or  four  hours'  work;  but  quite  often  no 
chloroform  is  needed. 

The  third  dose,  of  course,  is  not  to  be  given  if  two 
have  produced  the  desired  effect. 

Safety. — This  formula  seems  to  be  perfectly  safe. 
I  have  now  used  it  (July  15,  '07)  in  fully  400  capital  opera- 
tions without  an  alarming  symptom;  and  I  have  reports 
from  others  of  more  than  3000  cases  without  an  accident 
of  any  kind.  Judging  from  my  own  experience  and  that 
of  others  thus  far  reported  it  appears  (when  properly 
handled)  to  be  absolutely  safe  if  chemically  pure  agents  are 
employed,  just  as  chloroform  is  safe  only  when  free  from 
impurities  and  used  with  judgment. 

If  left  undisturbed,  soon  after  the  first  injection  the 
patient  sinks  into  a  tranquil  sleep;  a  few  minutes  after  the 
second  one  almost  total  unconsciousness  is  noted — always 
the  individual  is  brought  into  the  operating  room  free  from 
anxiety  and  excitement.  If  the  patient  is  anxious  it  is 
well  to  insure  a  good  night's  sleep  and  consequent  tran- 
quility  by  using  a  night-cap  dose  the  night  before,  when 
rarely  are  more  than  two  tablets  required  for  the  operation. 
The  avoidance  of  the  autotoxemia  of  excitement  and  fear 
no  doubt  plays  an  important  part  in  securing  the  excellent 
after-effects  following  the  use  of  this  anesthetic. 

Apparently  from  the  cactin,  Abbott  (hence  essential  in 
the  combination),  the  pulse  is  increased  to  90  or  100  or  mor^ 
and  is  full  and  strong,  even  though  the  patient  may  have 
been  brought  into  hospital  suffering  from  shock. 

The  respirations  sink  to  about  15,  to  12  or  8  or  even 
6  per  minute  (practically  the  same  as  in  deep,  normal 
slumber),  but  the  color  remains  good. 

The  reflexes  are  not  abolished,  nor  is  the  pupil  inactive 
to  light.  If  found  dilated  after  the  second  dose,  plain  mor- 
phine should  be  employed  for  the  third  (if  needed) — there- 


54  SURGICAL  THERAPEUTICS 

after  a  few  drops  of  chloroform  will  usually  suffice  to  com- 
plete the  anesthesia. 

The  skin  of  hard  drinkers  may  become  quite  mottled. 

While  the  patient  is  not,  as  a  rule,  profoundly  uncon- 
scious, the  analgesia  from  two  doses  is  sufficient  to  permit 
most  operations  like  curettage,  perineorrhaphy,  hernia,  re- 
section of  rib,  etc.  The  patient  may  make  a  little  com- 
plaint on  cutting  the  skin  or  pulling  on  the  peritoneum, 
but  with  the  use  of  a  few  drops  of  chloroform — sometimes 
none — hysterectomy  or  gallstone  operations  may  be  done 
readily,  or,  with  a  little  cocaine  for  the  skin,  extensive 
resection  of  the  bowel,  appendectomy,  etc. 

Under  three  full  doses  (an  hour  or  an  hour  and  a 
half  apart),  the  last  a  half  hour  before  cutting,  the  most 
extensive  and  prolonged  operations  may  be  performed: 
amputation  of  the  thigh,  trephining,  excision  of  the  mam- 
mary gland  and  axillary  contents,  removal  of  the  superior 
maxilla,  abdominal  hysterectomy,  Kraske's  operation  of 
removal  of  the  rectum,  Schede's  operation  of  excision  of 
chest-wall,  nephrectomy  and  thyroidectomy  being  some 
of  the  operations  I  have  made  without  the  use  of  a  drop 
of  chloroform. 

Respiratory  Failure. — Among  possible  dangers  cessation 
of  respiration  would  seem  to  be  most  likely  to  occur. 
Practically  I  have  never  seen  any  trouble,  except  in  one 
case  where  a  fat  woman's  tongue  dropped  into  the  pharynx 
— and  withdrawal  of  the  tongue  promptly  relieved  it. 
During  operative  work  the  respirations  generally  come  up 
to  the  normal;  after  operation,  if  they  should  drop  below 
six  per  minute,  very  strong  coffee  might  be  given  by  rectum, 
and  strychnine  administered:  i-i5th  grain  hypodermically. 
Or  by  shaking  his  shoulder  with  sharp  command,  the 
patient  may,  from  time  to  time,  be  made  to  breathe  volun- 
tarily. However,  in  no  case  thus  far  recorded  has  there 
been  the  slightest  alarm  (even  in  back-woods  farm  houses, 


ANESTHESIA  55 

with  inexperienced  nurses  in  charge,  as  much  of  my  work 
has  been)  as  to  respiratory  paralysis. 

Anuria. — Suppression  of  urine  is  one  of  the  greatest 
dangers  from  an  impure  scopolamine.  Dr.  G.  M.  Phillips, 
Professor  of  Genitourinary  Surgery  in  Barnes  University, 
St.  Louis,  has  had  two  deaths  from  "  scopolamine-mor- 
phine"  anesthesia,  and  Dr.  J.  C.  Murphy,  Professor  of 
Obstetrics  in  the  St.  Louis  College  of  Physicians  and 
Surgeons,  one — all  three  from  anuria  following  the  use  of 
socalled  "hyoscine"  tablets  prepared  by  the  firm  alluded 
to  by  Merck  as  the  heaviest  purchasers  of  "hyoscine"  (scopo- 
lamine) made  from  scopola  atropoides  and  therefore  likely 
to  contain  apoajropine,  etc. — their  basis  for  choice  being, 
apparently,  price  only. 

In  the  treatment  of  anuria  the  sulphate  of  sparteine 
in  doses  of  one  or  two  grains  hypodermically  every  three 
or  four  hours  has  been  found  most  effective  by  Stuart 
McGuire  of  Richmond.  Its  action  is  manifested  within 
thirty  minutes.  With  it  should  be  used  hypodermoclysis: 
one  liter  of  salt  solution  to  be  injected  into  the  cellular 
tissue  of  the  breast  or  buttock  and  repeated  in  three  or 
four  hours. 

Probably  it  is  best  not  to  use  this  form  of  anesthesia 
when  there  is  decided  nephritis. 

Heart  Failure. — Thus  far  there  has  never  been  any 
indication  of  failure  of  heart-action,  although  warning  has 
been  given  by  Abbott  and  others  that  there  might  be 
trouble  in  case  of  serious  organic  heart  lesions.  Abbott's 
addition  of  cactin  seems  to  have  settled  this.  Several  of 
my  patients  have  had  mitral  insufficiency,  but  the  cardiac 
rhythm  has  been  improved  rather  than  made  worse  by  its 
use.  Tablets  made  with  digitalin  instead  of  cactin  have 
not  been  nearly  as  satisfactory  as  those  after  the  regular 
formula.  The  suggestion  to  add  atropine,  ignorantly  made 
by  some,  is  the  sheerest  folly. 


56  SURGICAL  THERAPEUTICS 

Remote  effects  are  conspicuous  by  tneir  absence. 

There  is  no  nausea  or  vomiting  in  most  instances — a 
distinct  advantage  in  abdominal  surgery  which  every  sur- 
geon will  appreciate. 

There  is  no  constipation — generally  the  boweis  move 
spontaneously  the  day  after  operation  and  the  tongue 
cleans. 

Rarely  there  is  slight,  transitory  delirium  following  its 
use,  especially  noted  when  strychnine  is  given.  It  is  of 
not  the  slightest  consequence. 

A  few  patients  have  slept  too  long  to  suit  their  friends, 
and  most  doctors  also  fear  too  long  a  slumber.  Nearly 
always  the  patient  is  wide-awake,  even  after  three  full 
doses,  within  one  or  two  hours  after  being  returned  to 
bed.  The  longer  the  patient  sleeps  the  better,  eight  to 
twelve  hours  being  desirable.  Some  women  sleep  most 
of  the  time  for  twenty-four  hours,  waking,  or  being  easily 
awakened  for  taking  necessary  drink  and  food,  urinating, 
etc. 

A  conspicuous  feature  after  the  operation  is  the  freedom 
from  pain.  After  the  most  extensive  and  severe  opera- 
tions patients  are  perfectly  comfortable  during  the  hours 
usually  so  full  of  suffering  and  restlessness — hours  so  trying, 
so  exhausting. 

Severe  thirst  is  also  absent  unless  there  has  been  serious 
hemorrhage,  and  much  earlier  than  after  any  other  anes- 
thetic the  patient  may  have  both  food  and  drink. 

Shock  is  practically  eliminated  save  from  loss  of  blood 
or  long  exposure  of  viscera.  Use  of  this  anesthetic  demon- 
strates that  much  of  what  we  have  heretofore  called  "shock" 
is  the  effect  of  too  much  chloroform  or  ether. 

Age-Limit. — It  should  not  be  used  in  very  young  chil- 
dren (who  bear  morphine  badly)  nor  in  the  extremely  old. 
I  have  given  it  to  patients  70  years  of  age,  without  fear, 
but  on  the  other  hand,  I  have  declined  to  give  it  to  those 


ANESTHESIA  57 

of  not  over  the  age  of  60  who  had  atheromatous  vessels 
and  other  marked  evidences  of  old  age. 

Its  Use  in  Labor-Cases. — Its  field  of  usefulness  in  labor 
would  seem  to  be  almost  unlimited — for  under  two  or  three 
doses  delivery  may  be  rendered  practically  painless  and 
the  most  severe  obstetrical  operation  can  be  performed 
without  the  knowledge  of  the  mother.  Even  half-doses 
will  do  in  many  cases,  the  patient  being  delivered  pain- 
lessly without  losing  consciousness. 

It  does  not  seriously  interfere  with  uterine  contractions: 
the  action  of  the  combination  of  hyoscine  and  morphine 
upon  the  involuntary  muscles  being  practically  nil;  contrary 
to  our  experience  with  anesthetic  inhalants,  under  profound 
anesthesia  the  pupillary  reflex  is  present,  peristalsis  con- 
tinues, etc.  If,  at  the  beginning  of  the  first  stage,  one 
gram  (15  grains)  of  quinine  be  given,  labor  will  progress 
even  during  total  unconsciousness.  If  it  is  delayed  in  the 
second  stage,  the  forceps  should  be  used. 

In  labor  good  judgment  should  be  exercised.  If  a  single 
pronounced  effect  is  desired,  one  full  dose  may  be  given; 
but  if  prolonged  effect  is  essential,  half  the  dose  early  and 
repeated  in  one  or  two  hours  is  perhaps  better. 

So  far  as  noted  in  the  numerous  cases  reported  it  does 
not  affect  the  fetus  in  any  undesirable  way,  except  that 
there  is  perhaps  a  little  more  than  the  usual  amount  of 
trouble  in  making  the  child  breathe;  but  no  fatalities  have 
been  recorded  traceable  to  the  use  of  the  anesthetic. 

It  is  best  to  give  it  only  after  the  os  is  dilated  so  far  as 
to  admit  two  fingers,  though  in  prolonged  "first  stage" 
it  may  be  given  at  any  time  the  patient  begins  to  com- 
plain bitterly.  In  an  hour  and  a  half,  if  needed,  a  second 
dose  may  be  injected;  and  a  half  hour  later,  unless  the 
patient  is  unusually  nervous,  forceps-delivery  may  be  made 
and  the  perineum  repaired  without  the  knowledge  of  the 
patient. 


58  SURGICAL  THERAPEUTICS 

Occasionally  a  third  dose  may  be  necessary  in  contracted 
pelvis  or  for  cesarean  section.  It  should  never  be  given 
sooner  than  three  hours  after  the  first  dose,  i.  e.,  one  and 
a  half  hours  after  the  second. 

In  Emergency  Surgery 

Its  value  in  emergency  work  can  scarcely  be  overesti- 
mated. In  .a  serious  calamity  where  many  are  involved  and 
help  is  scarce  (as  in  railroad  accidents,  explosions,  huge 
fires,  etc.)  it  is  of  the  utmost  utility.  Every  hospital,  every 
emergency-surgeon,  every  ambulance-man  should  be  sup- 
plied, as  should  also  every  army-surgeon,  whether  in  divi- 
sion-hospital, in  the  field-hospital  or  on  the  firing-line;  the 
possible  diminution  of  human  suffering  by  use  of  this 
hypnotic-analgesic-anesthetic  combination  is  beyond  estima- 
tion. It  relieves  pain,  reduces  shock  and  puts  the  patient 
in  best  possible  condition  for  a  general  anesthetic  if  a  third 
dose  be  deemed  inadvisable. 

To  those  who  are  afraid  or  skeptical  the  following 
advice  is  given: 

One  hour  before  a  serious  operation  administer  one  tablet; 
see  how  little  chloroform  will  be  required  and  how  little 
Postoperative  suffering  there  will  be. 

After  a  few  trials,  give  one  dose  two  hours  before  and  a 
second  dose  half  an  hour  before  operation;  see  how  few 
(especially  women)  will  require  any  chloroform  at  all. 

And,  finally,  when  accustomed  to  its  effects,  try  the  third 
dose,  as  directed,  in  appropriate  cases. 

Statistical 

Reports  were  solicited  from  physicians  known  to  be 
employing  the  hyoscine-morphine-cactin  anesthesia  in 
their  surgical  and  obstetrical  practice,  and  their  replies 
were  tabulated  in  my  paper  as  it  originally  appeared  in 
The  American  Journal  of  Clinical  Medicine.  Briefly 
recapitulated  the  facts  are  as  follows: 


ANESTHESIA  59 

Altogether  311  answers  were  received,  reporting  on 
a  total  of  2432  cases.  Of  these,  134  fail  to  give  the  num- 
ber of  cases  in  which  it  was  used.  The  other  177  have 
employed  it  in  665  labors  and  in  1,767  surgical  operations 
— without  any  serious  mishap,  and  but  8  failures!  Some 
of  the  failures  were  unquestionably  due  to  faulty  technic. 
The  trouble  in  securing  good  respiration  in  the  newly- 
born  was  produced  by  too  large  dosage — semihypnosis 
being  best  for  confinements:  memory  of  "pains"  is  totally 
obliterated  in  most  cases  from  half  the  dosage  necessary 
for  surgical  work. 

My  opinion  is  that  ultimately  this  combination  will  be 
used  most  extensively  for  partial  anesthesia — total  uncon- 
sciousness being  induced  by  a  trifling  amount  of  chloro- 
form by  inhalation;  the  full  analgesic  effect  of  three  doses 
being  reserved  chiefly  for  those  cases  in  which  for  any  rea- 
son it  would  be  injudicious  to  use  chloroform  or  ether. 
But  in  my  own  work  I  am  using  it  for  practically  all  major 
operations — the  narcosis  is  entirely  too  profound  for  minor 
surgery  (although  the  supplemental  one-dose  method  works 
well);  and  I  am  sure  that  others  who  try  it  carefully,  in 
appropriate  cases,  will  become  as  enthusiastic  as  I  am,  on 
account  of  (a)  its  simplicity,  (b)  its  freedom  from  post- 
operative nausea  and  pain,  (c)  its  economy  and  (d)  its 
attractiveness  to  patients  who  so  greatly  dread  either 
chloroform  or  ether. 

Precautions 

Certain  precautions  are  essential: 

i.  The  hyoscine  must  be  free  from  atroscine  and 
apoatropine,  especially  the  latter,  since  contamination  with 
these,  antagonizes  the  effect  sought — hence  the  hyoscine 
hydrobromide  used  must  be  from  a  reliable  manufacturer; 
and  there  must  be  no  thebaine  or  atropine  in  the  mor- 
phine. 


60  SURGICAL  THERAPEUTICS 

2.  Silence  must  be  preserved  in  the  operating  room; 
otherwise  the  patient  becomes  restless,  and  finally  wide- 
awake and  excited.     Stop  ears  with  cotton. 

3.  It  should  not  be  used  in  the  very  young  or  in  those 
of  extreme  old  age.     Possibly   it  may  be   of  danger   in 
serious   heart -lesions.        Abbott    says    it    should-  not    be 
given  to  those  suffering  from  far-advanced  nephritis. 

4.  If  the  patient  is  nervous  it  is  well  to  tie  his  hands 
behind  the  neck  so  that  a  sudden  movement  may  not  con- 
taminate the    field    of    operation.     The    feet    also    may 
be  tied,  in  all  cases  perhaps. 

5.  The  stomach  and  bowels  should  be  empty,  as  for 
chloroform-anesthesia . 

6.  The  Abbott  hyoscine-morphine-cactin  tablet  should 
always  be  employed.     One  may  depend  on  Abbott's  prep- 
arations. 

7.  If  anesthesia  is: not  complete,  a  fev,  drops  of  chloro- 
form by  inhalation  will  cause  almost  instant  snoring.    Re- 
peat as  needed. 

Effects 

1.  The  analgesia  appears  to  be  complete  for  many 
hours.     In  two  cases  where  hypodermoclysis  was  ordered 
several  hours  after  each  patient  had  been  returned  to  bed, 
there  was  no  indication  of  sensation  when  the  large  needle 
was  introduced. 

2.  The  first  effect  is  an  excitement — in  two  of  my 
cases  delirium  developed — with  slight  dilation  of  the  pupils. 
Then  the  patient  becomes  quiet  and  the  pupils  are  midway 
between    dilation    and    contraction.     Soon,    in    favorable 
cases,  deep  sleep  follows. 

3.  After  the  second  injection  (which  may  arouse  the 
patient)  profound  sleep  will  be  noted  in  most  cases;  but 
some  subjects  insist  upon  muttering  or  even  talking  through- 
out the  operation,  though  making  no  complaint  about  its 
hurting  and  knowing  nothing  of  it  on  awakening.  , 


ANESTHESIA  61 

4.  Sleep  continues  for  many  hours,  in  most  instances, 
if  three  injections  are  used.     Friends  must  be  advised  in 
advance  that  the  sleep  may  continue  twelve  hours  or  more ; 
and  that  without  danger  if  patient  is  watched  and  aroused 
if  respirations  sink  below  six  per  minute. 

5.  The  patient  can  be  aroused  at  any  time  by  shaking 
or  a  loud  command,  and  may  be  made  to  assist  in  changing 
position  or  to  sit  up  for  application  of  bandages,  etc.     In 
a  fraction  of  a  minute,  or  at    most  in  two  or  three  min- 
utes, slumber  is  again  deep  and  other  operative  work  may 
be  done. 

6.  The  secretions  are  not  greatly  interfered  with. 

7.  Peristalsis   is  not   arrested,   as  one  would  expect 
from  so  large  a  dose  of  morphine. 

Remarks 

1.  Women  seem  to  require  less  than  men.  (Which  is 
true  of  any  anesthetic.) 

2.  Ether    should    as    a    rule   not  be  given  with   the 
hyoscine-morphine   combination;    if    anything  is  needed, 
chloroform  is  best.     (The  few  reports  on  the  use  of  ether 
following  H-M-C  are  favorable.) 

3.  A  beautiful  thing  about  the  method  is  the  absence 
of  vomiting — of  great  importance  in  abdominal  surgery. 
Another  favorable  feature  is  the  absence  of  postoperative 
pain;  patients  usually  sleep  all  night  following  operation  and 
awake  next  morning  demanding  breakfast. 

4.  It  is  the  ideal  method  of  producing  anesthesia  for 
obstetrical  work,   particularly  for   delivery   with   forceps. 
It  does  not  greatly  retard  labor. 

5.  If  the  patient  moves  -or  groans  during  operation, 
the  temptation  to  give  chloroform  should  not  hastily  be 
yielded  to;  all  that  is  usually  necessary  is  to  say  in  a  pos- 
itive way:     "Lie  still!     You'll    not  be  hurt,"    wait  until 
sleep  or  perfect  quietude  is  resumed,  then  proceed. 


62  SURGICAL  THERAPEUTICS 

6,  While  the  effects  of  the  compound  are  decided, 
suggestion  may  properly  be  utilized  to  aid  the  action  and 
render  smaller  doses  necessary. 

Disadvantages 

1.  The  only  serious  disadvantage  that  I  have  noted 
is  that  muscular  relaxation  is  not  absolute — so  that  it  is 
not  applicable  to  very  delicate  work,  like  that  on  the  eye. 
In  flap-amputations  this  is  a  great  help. 

2.  It  cannot  always  be  used  with  a  crowd  around, 
as  in  a  clinic,  excitation  being  likely  to  result  from  the 
noise. 

3.  After  one  has  become  accustomed  to  it  there  is 
a  tendency  to  do  one's  work  too  slowly — it  induces  laziness 
on  the  part  of  the  surgeon,  who  quickly  learns  that  he 
doesn't  have  to  make  haste. 

Advantages 

1.  Economy.     About  three  cents  covers  the  entire  cost 
of  several  hours'  anesthesia. 

2.  No  assistant  is  necessary  in  many  operations — save 
as  a  precaution  against  lawsuits  (abortions,  railway  in- 
juries and  the  like). 

3.  No  nausea  or  vomiting;  this  is  of  special  advantage 
in  abdominal  work. 

4.  No  shock.     There  is  no  shock  (except  from  great 
loss  of  blood)  with  this  anesthetic.     Its  use  demonstrates 
that  most  operative  "shock"  is  the  result  of  too  much 
chloroform  or  ether. 

5.  No  pain,   or  but   little,   after  operation;   a   great 
inducement   to  patients  reluctant   to   submit   to   surgical 
treatment. 

6.  Absence  of  fear  of  chloroform  or  ether  on  the  part 
of  either  patient  or  surgeon;  the  advantage  of  not  having 
to  hurry  because  the  patient  does  net  take  the  anesthetic 
well  can  scarcely  be  overestimated. 


ANESTHESIA  63 

7.  Fear  of  operation  disappears,  and  with  it  all  objec- 
tions to  the  surgeon's  work  and  all  mentally-induced  auto- 
toxemia  is  prevented. 

8.  The  danger  of  hemorrhage  is  much  decreased. 

9.  Gauss's  analysis  of  his  1000  obstetric  cases  shows 
a  reduced  mortality  of  mothers  and  infants,  and  even  greater 
advantages  from  preventing  the  impression  on  the  nervous 
system  made  by  the  agonies  of  childbirth.     Many  reports 
show  how  the  use  of  the  H-M-C  (Abbott)  anesthesia  dis- 
sipates the  fear  of  maternity. 

Lumbar  Anesthesia. — Injection  of  cocaine  solution 
into  the  spinal  column  gives  perfect  analgesia  of  some 
hours'  duration,  below  the  neck.  So  also  does  an  injection 
of  small  quantities  of  sulphate  of  magnesium.  How- 
ever, these  are  very  dangerous;  eight  deaths  are  on  record 
and  many  others  have  not  been  reported.  In  the  light  of 
our  present  knowledge  the  method  is  scarcely  justifiable. 
If  used  at  all,  it  should  be  limited  to  (i)  aged  patients, 
(2)  those  affected  with  arteriosclerosis,  (3)  persons  who 
have  cardiac  lesions,  (4)  subjects  of  bronchial  and  pul- 
monary disease. 

Method  of  Use. — The  method,  as  described  (for  tropa- 
cocaine)  by  McCombs  (The  American  Journal  of  Clinical 
Medicine) is  as  follows:  The  syringe  employed  is  a  Luer 
all  glass,  with  graduated  barrel,  capacity  25  minims.  The 
needles  are  three  inches  long,  have  a  pointed  tip  and 
dull  edge,  thus  separating  the  tissues  and  not  cutting 
out  a  plug.  The  needle  connects  with  the  syringe  by 
a  joint. 

The  needles  with  rammers  are  thoroughly  boiled, 
also  the  syringe,  the  piston  being  removed  from  barrel. 
Dip  the  tube  or  vial  containing  the  tropacocaine  in  an 
antiseptic  solution  and  dry  with  sterile  gauze.  Break  the 
tube  or  remove  cork  and  roll  the  powdered  tropacocaine 
into  the  bottom  of  the  barrel.  Slowly  introduce  the  piston, 


64  SURGICAL  THERAPEUTICS 

being  careful  not  to  blow  the  powder  out  of  the  end  of 
the  barrel. 

How  to  Locate  the  Point  of  Puncture. — The  syringe 
is  laid  within  easy  reach  of  the  right  hand.  The  patient's 
pulse,  being  taken,  will  register  from  80  to  100  from  men- 
tal anxiety  and  fear  of  operation.  The  lumbar  region  is 
cleaned  and  the-third  or  fourth  intervertebral  space  located. 
This  is  done  by  having  patient  flex  and  extend  the  trunk, 
while  the  finger  locates  the  dimple  or  depression  below 
the  tip  of  the  spine.  In  lean  patients  this  is  quite  easy. 
In  fleshy  patients  stretch  the  edge  of  a  towel  from  the 
highest  points  of  the  crests  of  the  ilia;  the  fourth  inter- 
space is  on  this  line.  Now  have  the  patient  lie  on  the  side 
and  flex  the  spine,  or  better  still,  have  him  sit  on  the  edge 
of  the  operating  table  and  bend  forward  until  the  folded, 
flexed  elbows  rest  upon  his  knees,  arching  his  spine.  If 
he  does  not  arch  the  spine  an  assistant  may  press  back- 
wards on  his  abdomen';  this  procedure  widens  the  inter- 
space between  the  vertebrae  to  its  greatest  extent  and 
serves  to  secure  the  success  of  the  operation. 

Making  the  Injection. — Now  with  the  exact  spot 
located,  allay  the  patient's  fears  by  telling  him  you  are 
not  going  to  stick  him  with  a  needle,  and  not  to  jump 
or  jerk.  The  operator  kneels  on  the  opposite  side  of 
the  table,  his  left  index  finger  on  the  intervertebral  depres- 
sion, below  the  spine  of  the  fourth  vertebrae  in  the  mid- 
line,  not  to  one  side,  with  the  needle  in  the  right  hand  and 
at  right  angles  to  the  skin  surface.  Make  slow  but  firm 
pressure  on  the  needle  to  press  it  through  the  thick  skin. 
If  bone  is  struck  the  resistance  is  decided,  and  the  needle 
must  be  slightly  withdrawn  and  direction  changed.  If 
the  intervertebral  space  is  entered,  the  needle  imparts 
to  the  hand  a  peculiar  cartilaginous  crepitus,  followed 
by  lessened  resistance  as  the  needle  enters  the  spinal 
canal,  and  clear  fluid  appears  at  the  needle  end.  Quickly 


ANESTHESIA  65 

place  left  index  finger  over  needle  end,  to  prevent  the 
escape  of  any  fluid,  and  attach  syringe  by  means  of  joint. 
Gently  pull  out  the  piston  until  spinal  fluid  fills  the  barrel 
to  the  8-  or  i5-minims  mark,  and  by  turning  the  syringe 
two  or  three  revolutions,  the  tropacocaine  will  quickly 
dissolve  in  the  spinal  fluid.  Now  press  the  piston  clear 
in,  tell  the  patient  to  straighten  up  his  back,  and  as  he 
does  so,  remove  the  syringe  and  needle.  The  skin  puncture 
is  covered  by  cotton  and  collodion. 

The  patient  can  now  be  prepared  for  the  operation, 
and  by  the  time  he  is  washed  up  anesthesia  will  be  com- 
plete; in  from  two  to  five  minutes  for  operations  below 
the  diaphragm  and  three  to  fifteen  above,  and  will  con- 
tinue for  one  and  one-quarter  to  three  hours. 

Anesthesia  is  complete  and  any  operation  may  be  done. 
Only  the  sensations  of  pain  and  temperature,  however, 
are  destroyed,  the  pressure  and  muscular  sense  being  un- 
affected. For  example,  the  patient  can  feel  the  pressure 
of  a  hand  against  him  or  as  one  seizes  a  group  of  muscles 
but  he  cannot  feel  cutting  or  crushing  instruments.  He  is 
able  to  walk  (though  this  is  not  advisable),  can  flex  or 
extend  his  limb  at  command,  and  so  assist  the  operator  if 
necessary;  he  has  perfect  control  of  his  higher  mental 
faculties,  can  answer  questions  intelligently  or  make  state- 
ments which  might  be  of  value  both  to  patient  and  phy- 
sician. 

Phenol  a.  Local  Anesthetic. — For  making  small 
incisions  in  the  skin  (like  opening  an  abscess,  cutting 
out  the  end  of  a  needle,  etc.),  an  anesthesia  may  be  pro- 
duced by  the  use  of  phenol  liquefactum — i.  e.,  liquefied 
95-percent  carbolic  acid — when  no  other  agent  is  at  hand. 
A  spot  an  inch  or  more  may  be  painted  with  the  pure 
phenol.  For  a  brief  space  of  time  there  will  be  a  burn- 
ing sensation,  succeeded  almost  instantly  by  a  cool  feel- 
ing as  the  skin  turns  white  and  shrivels.  In  a  few  minutes 


66  SURGICAL  THERAPEUTICS 

the  skin  may  be  cut  without  pain,  but  underlying  struc- 
tures are  not  insensitive  to  the  knife.  It  does  not  seem 
to  interfere  with  healing  under  a  sterile  dressing,  and 
possesses  the  advantage  of  thoroughly  sterilizing  the 
superficial  layers  of  the  skin. 

Tropacocaine  for  Spinal  Anesthesia. — Better  than 
cocaine  for  the  production  of  anesthesia  by  intraspinal 
injection  is  tropacocaine.  It  is  claimed  that  in  many 
thousands  of  anesthesias  produced  by  it  the  headache 
and  nausea  were  no  more  marked  than'  after  simple  spinal 
puncture,  and  no  dangerous  effects  were  seen.  The 
technic  differs  from  that  usually  employed,  in  that  the 
tropacocaine  in  powder  is  placed  in  a  sterile  glass,  and 
the  spinal  fluid  being  drawn  into  the  glass  dissolves  the 
substance,  no  water  being  added.  For  operations  on  the 
legs  and  perineum,  3-4  grain  suffices,  but  for  the  abdo- 
men i  grain  is  required.  It  should  not  be  used  in  chil- 
dren less  than  fourteen  years  old,  although  old  age  is  not 
a  contraindication.  As  it  lowers  blood-pressure  it  may 
be  dangerous  in  persons  whose  blood-pressure  is  already 
low.  Increased  extent  of  anesthesia*  must  be  obtained 
by  raising  the  pelvis  and  not  by  increasing  the  dose. 

Vomiting  After  Anesthesia. — Vomiting  after  anes- 
thesia will  cease  spontaneously  in  a  few  hours  (twenty- 
four  at  the  farthest)  unless  acute  sepsis  is  coming  on, 
provided  all  water  or  other  fluid  is  scrupulously  avoided. 
Above  all  things,  ice  in  the  mouth  should  not  be  per- 
mitted— it  tends  to  prolong  nausea  indefinitely;  but  the 
tongue  and  lips  may  be  moistened  every  few  minutes 
with  a  cloth  wrung  from  ice-water.  For  wealthy  patients 
a  little  iced  champagne  may  be  ordered  after  eight  hours 
— a  half  teaspoonful  every  half-hour  until  the  end  of  the 
first  twenty-four  hours,  when,  if  vomiting  has  ceased, 
water  may  be  given  cautiously;  if  it  is  thrown  up,  another 
twelve  hours  of  abstinence  must  be  enforced.  For  patients 


ANEURISM  67 

who  cannot  afford  champagne,  one  drop  of  phenol  in  a 
teaspoonful  of  peppermint  water  may  be  ordered  every 
hour,  if  the  patient  and  friends  demand  something  in 
the  way  of  medication.  But  the  best  remedy  is  perfect 
quietude  and  withholding  of  fluids. 

ANEURISM. 

Aneurism,  whenever  possible,  should  be  subjected  to 
operative  treatment:  excision  or  at  least  ligation.  Inser- 
tion of  silver  wire  into  the  aneurismal  sac  has  many  enthu- 
siastic advocates,  notably  MacEwan,  who  has  had  some 
splendid  results.  But  when  so  situated  as  to  be  inaccessible 
(as  in  the  thorax)  or  inoperable  (as  of  the  abdominal  aorta), 
or  from  size,  certain  medical  and  dietetic  measures  may  be 
instituted. 

The  subcutaneous  injection  of  gelatin  has  been  highly 
lauded.  It  is  liquefied  and  injected  into  the  buttock  with 
a  specially  constructed  syringe.  It  is  presumed  to  add 
materially  to  the  coagulability  of  the  blood;  but  its  use- 
fulness is  doubtful. 

Aneurism  of  Aorta. — Silver  wire  may  be  introduced 
into  the  aneurismal  sac  through  a  fine  canula,  insertion 
being  made  at  the  point  where  pulsation  is  most  promi- 
nent. The  skin  is  carefully  sterilized,  the  boiled  canula 
and  trocar  thrust  in,  the  trocar  withdrawn  and  the  open- 
ing instantly  closed  by  means  of  sterile  gauze;  then  from 
fifteen  to  thirty  feet  of  No.  28  silver  wire  may  be  slowly 
passed  in.  When  a  sufficient  quantity  has  been  made  to 
coil  up  in  the  sac,  the  canula  is  to  be  withdrawn  and  the 
proximal  end  of  the  wire  fastened  to  the  chest-wall  by 
adhesive  plaster.  No  anesthetic  is  necessary.  At  the  same 
time  one  may  inject  into  the  buttock  about  300  Cc.  of  a 
2 -percent  gelatin  solution,  which  is  presumed  to  facilitate 
coagulation  "of  blood.  If  the  wire  causes  pain  after  a  time 
— two  or  three  weeks — a  part  of  it  may  be  very  cautiously 


68  SURGICAL  THERAPEUTICS 

withdrawn,  though  this  is  dangerous  on  account  of  the 
possibility  of  loosening  some  part  of  the  clot.  If  the 
open  pleura  have  been  punctured  in  the  introduction  of 
the  trocar,  hematothorax  may  develop  and  cause  distressing 
symptoms  and  sometimes  death.  So  extreme  care  should 
be  taken  not  to  puncture  it.  In  abdominal  aneurism  it 
is  best  to  make  an  abdominal  section  at  the  time  of  in- 
serting the  wire.  Some  cures  have  been  recorded — and 
many  failures. 

Calcium  Chloride  for  Aneurism. — A  remedy  for 
inoperable  aneurism  which  has  attracted  considerable  atten- 
tion of  late  is  calcium  chloride.  It  is  well  known  that 
the  lime  salts  taken  for  a  long  time  increase  the  coagu- 
lability of  the  blood;  so,  theoretically,  when  an  aneurism 
is  to  be  treated  by  the  "rest"  method  or  by  insertion  of 
wire  into  the  sac,  the  use  of  calcium  salts  ought  to  be 
of  decided  benefit.  Practically  applied  it  seems  to  be 
of  service  in  non-operative  treatment;  and  it  certainly  will 
do  no  harm  to  give  it  for  some  days  before  needling  or 
wiring  is  to  be  tried.  It  may  be  given  in  quarter-gram 
to  half-gram  doses  (3  to  8  grains)  three  times  a  day. 
Plenty  of  water  must  be  given  with  it. 

Iodides  for  Aneurism. — The  pain  and  throbbing  of 
inoperable  aneurisms  often  may  be  ameliorated  by  the 
internal  use  of  iodide  of  potassium.  Even  though  there 
may  be  no  suspicion  of  syphilis  as  a  cause,  the  iodide  should 
be  tried  before  resorting  to  morphine  or  other  opiates, 
In  doses  of  one  to  two  Grams  (15  to  30  grains)  three  times 
a  day,  with  enforced  quietude  and  restricted  diet,  it  affords 
perfect  immunity  from  suffering;  but  it  may  have  to  be  con- 
tinued for  many  months,  the  slightest  reduction  from  the 
dose  of  tolerance  causing  immediate  return  of  the  pain. 
It  is  presumed  to  act  by  depressing  the  heart,  though  it 
may  have  some  direct  effect  upon  the  diseased  vessel- 
walls  (especially  in  cases  due  to  syphilis).  In  some  cases, 


ANGIOMA  69 

undoubtedly  luetic,  it  is  necessary  to  increase  the  dose  to 
five  or  six  grams  thrice  daily.  A  few  cures  have  been 
reported. 

Threatened  Rupture  of  Aneurism. — When  an 
aneurism  threatens  to  rupture  through  the  skin  (as  is 
frequently  the  case  with  the  femoral,  carotids,  and  even 
the  aorta)  the  following  treatment  should  be  instituted: 

The  patient  must  be  put  in  bed  and  perfect  quietude 
enforced;  if  one  of  the  extremities  be  affected  it  should  be 
immobilized  by  some  kind  of  splint;  if  the  neck  be  the 
site  of  trouble  the  head  must  be  fixed  between  sand-bags, 
with  no  pillow.  Enough  morphine  to  keep  the  patient 
tranquil  is  advisable.  Diet  must  be  restricted  to  a  very 
little  of  the  most  nutritious  of  foods  and  the  amount  of 
drink  limited  to  the  least  possible.  Veratrine  in  doses  of 
one  milligram  (gr.  1-67)  is  to  be  taken  every  half  to  two 
hours  until  the  pulse  is  soft  and  weak;  and  then  three  or 
four  times  a  day  to  maintain  it  so.  Iodide  of  potassium 
is  to  be  given  in  doses  of  a  half  gram  (8  grains)  three  times 
a  day  and  rapidly  increased  until  four  grams  (60  grains) 
are  taken  at  a  dose — and  this  whether  or  not  the  patient 
has  had  syphilis;  if  he  has,  the  increase  may  be  con- 
tinued to  a  much  greater  dosage,  a  half  ounce  or  more 
thrice  daily  often  being  tolerated  by  luetics.  Locally,  the 
best  treatment  is  to  paint  with  collodion  night  and  morn- 
ing. 

Under  this  plan  many  cases  have  been  greatly  relieved 
and  some  apparently  cured. 

ANGIOMA 

This  tumor  is  one  composed  entirely,  or  in  great  part, 
of  blood-vessels — mostly  of  new  formation.  In  women 
they  sometimes  become  distended,  or  more  prominent, 
at  the  menstrual  period.  The  majority  are  congenital; 
very  rarely  angiomata  develop  after  puberty.  Their 


70  SURGICAL  THERAPEUTICS 

growth  is  commonly  painless,  slow  and  irregular.  Some- 
times ulceration  of  the  skin  occurs — with  either  alarming 
hemorrhage  or  spontaneous  cure  of  the  growth.  They 
should  be  removed  by  operation  when  they  are  conspicu- 
ous or  when  they  show  a  tendency  to  grow. 

ANKLE:  DISEASES  OF 

Drainage  of  Ankle. — Drainage  of  the  ankle  as  usually 
practised  is  very  unsatisfactory,  and  a  panarthritis  usually 
develops,  in  many  cases  necessitating  an  amputation 
through  the  leg.  This  has  led  to  the  devising  of  a  more 
satisfactory  plan  of  drainage.  The  ankle  joint  consists 
not  of  a  single  compartment  lined  by  a  synovial  membrane 
but  rather  of  two,  one  anterior,  the  other  posterior,  sepa- 
rated from  one  another  by  the  astragalus  and  the  two 
malleoli,  and  in  communication,  so  far  as  the  flow  of 
synovia  or  exudate  is  concerned,  only  by  narrow  channels 
beneath  the  lateral  ligaments.  Hence  drainage  conditions 
can  best  be  met  by  removal  of  the  astragalus.  The 
method  of  the  removal  of  the  astragalus  depends  upon  the 
original  injury.  It  is  most  accessible  through  an  incision 
over  its  head  parallel  to  and  to  the  outer  side  of  the 
extensor  tendons,  made  with  the  foot  strongly  adducted. 
The  resultant  stage  is-  as  good  if  not  better  than  where, 
even  if  the  leg  is  saved,  a  stiff  and  tender  ankle  is  ob- 
tained. 

Sprained  Ankle* — As  the  x-ray  has  shown  that  large 
numbers  of  socalled  sprains  of  the  ankle  are  sprains  plus 
fracture,  examination  with  the  fluoroscope  is  advisable 
whenever  possible.  If  fracture  be  found,  plaster-paris 
dressing  and  perfect  rest  of  the  joint  for  three  weeks  is 
advisable.  If  no  fracture  is  present,  massage  and  dressing 
with  strips  of  surgeon's  plaster  is  perhaps  best,  with  imme- 
diate use  of  the  limb.  But  in  case  of  severe  injury  tota) 
rest  is  preferable. 


ANTISEPTICS  71 

ANTHRAX 

Three  conditions  are  grouped  under  the  name 
"anthrax." 

1.  Benignant  anthrax,  characterized  by  a  peculiar  car- 
buncle; a  painful,  dark-colored  tumor  in  the  subcutaneous 
cellular  tissue,  which  becomes  much   inflamed  and   then 
necrotic,  discharging  a  fetid,  bloody  pus.     It  is  a  purely 
local  infection  with  bacillus  anthracis  (i.  e.,  without  any 
anthracemia)  and  is  not  a  fatal  disease.     Early  excision 
and  thorough  cauterization  of  the  wound  by  nitric  acid 
or  the  Paquelin  cautery  is  the  proper  treatment;  the  re- 
sultant sore  being  handled  just  like  a  simple  burn. 

2.  Malignant   anthrax,    the   "malignant  pustule"   of 
older  writers,  or  "wool-sorters'  disease":  infection  from 
animals  suffering  with  splenic  fever.     The  pustular  trouble 
gradually  extends  until  the  whole  system  is  involved,  the 
intestinal  tract  finally  is  invaded  and  gives  rise  to  what 
is   called   "the   intestinal   type"   of   anthrax.     The   local 
lesion  is  treated  in  the  same  manner  as  in  the  benignant 
form;  the  anthracemia  by  injection  of  the  Pasteur  serum. 

3.  Symptomatic  anthrax,    the  disease  called  "black- 
leg"  in  sheep   (quarter-evil).     It  is  due  to  the  bacillus 
Chauvaei. 

ANTISEPTICS 

Antiseptic  and  Germicidal. — It  is  strange  that  medi- 
cal men  apparently  well  educated  will  use  the  word  "anti- 
septic" as  the  equivalent  of  "germicidal."  The  word 
germicide  means  anything  which  will  kill  a  germ — a  term 
formerly  regarded  as  meaning  "bugs",  or  microscopic 
animals  of  some  kind,  instead  of  the  minute  fungi — invis- 
ible plants — which  play  such  an  important  part  in  disease; 
whereas  "antiseptic"  simply  implies  some  agent  which 
will  inhibit  the  growth  of  microorganisms,  antagonize  or 
destroy  their  poisonous  products  or  prevent  the  absorp- 


72  SURGICAL  THERAPEUTICS 

tion  of  their  toxins.  We  employ  antiseptic  precautions  in 
preparing  for  and  performing  an  operation;  we  wash  our 
hands  in  germicidal  solutions.  Asepsis  and  antisepsis  also 
should  never  be  used  interchangeably,  as  is  so  often 
done. 

Antiseptic  Dusting  Powder. — To  replace  the  costly 
proprietary  articles  used  for  dusting  on  wounds  the  United 
States  Pharmacopeia  recommends  "thymolis  iodidum" — 
the  iodide  of  thymol.  It  is  now  prepared  of  standard 
U.  S.  P.  strength  by  all  leading  manufacturing  chemists  and 
can  be  obtained  on  prescription  from  all  first-class 
druggists. 

Antiseptic  Solution:  General. — A  most  useful  anti- 
septic to  use  for  douches,  irrigations,  etc.,  is  the  "liquor 
cresolis  compositus"  of  the  United  States  Pharmacopeia. 
It  is  of  the  same  strength  as  "lysol"  and  may  be  used  by 
those  who  prefer  a  non-proprietary  preparation.  The 
formula  is: 

Cresol,  pure   500  parts 

Linseed  oil 350  parts 

Potassium  hydroxide    80  parts 

Water,  enough  to  make    1000  parts 

Mix.     Mark:    "Poison." 

It  is  about  the  same  strength  as  carbolic  acid.  Solu- 
tions, i  to  40,  in  water  are  highly  germicidal. 

Dobell's  Solution. — This  excellent  antiseptic  solu- 
tion, of  especial  use  in  nasal  and  laryngological  work, 
now  should  be  of  uniform  strength  wherever  prepared,  the 
National  Formulary  specifying  that  it  shall  contain : 

Sodium  borate   Gm.    15.0  (oz.         1-2) 

Sodium  bicarbonate  .  Gm.    15.0  (oz.         1-2) 

Phenol Gm.      3.0  (grs.  45        ) 

Glycerin Cc.      35.0(023.    i  1-6) 

Water,  to  make Cc.  1000.0  (ozs.  32       ) 


ANTISEPTICS  73 

Harrington's  Solution. — One  of  the  best  antiseptic 
agents,  if  not  the  best,  is  Harrington's  solution.  It  has 
this  composition: 

Hydrochloric  acid 60.0  parts 

Alcohol  (94  percent) 640.0  parts 

Water 300.0  parts 

Bichloride  of  mercury o.i  part 

Experiments  show  that  this  solution  will  sterilize  car- 
buncle-pus in  less  than  thirty  seconds,  while  it  requires 
tricresol  five  and  one-half  minutes,  and  carbolic  acid 
four  minutes,  to  produce  the  same  results.  It  is  especially 
useful  for  hand  disinfection  and  for  use  in  preparing  the 
skin  for  incision.  On  account  of  the  corrosive  sublimate 
it  contains  it  should  be  preceded  by  ether  and  followed 
by  a  little  plain  water. 

Sterilization  of  Knives. — The  question  is  •  often 
asked:  How  may  knives  be  sterilized,  as  boiling 
dulls  them  so  ?  Royster,  as  the  result  of  experiments 
and  of  correspondence  with  a  large  number  of  oper- 
ators, has  reached  the  following  conclusions:  "  (i) 
Knives  can  be  safely  sterilized  by  chemical  and  me- 
chanical means  without  the  use  of  heat  in  any  form. 
(2)  The  majority  of  American  surgeons  are  using  car- 
bolic acid,  or  alcohol,  or  both.  (3)  Immersion  in  ninety- 
five-percent  alcohol  has  the  least,  and  boiling  the  most, 
effect  in  dulling  the  edge  of  a  knife."  To  all  of  which 
I  want  to  offer  the  most  strenuous  objection.  After  a 
knife  has  been  in  a  streptococcus  abscess  nothing  but 
boiling  is  safe!  Boiling  does  not  seriously  dull  a  knife 
if  it  be  boiled  in  a  very  strong  solution  of  washing  soda 
(sal  soda);  cooking  soda  (bicarbonate  of  soda)  will  not 
do — it  is  absolutely  useless;  but  the  carbonate  (sal  soda) 
can  be  relied  upon  invariably.  I  have  a  knife  which  has 
been  boiled  5000  times  and  it  still  ''works."  Of  course 
the  knife  is  sharpened  now  and  then. 


74  SURGICAL  THERAPEUTICS 

Thymol. — This  stearoptene  derived  from  thyme  and 
other  vegetable  oils  is  a  more  powerful  antiseptic  than 
phenol  (carbolic  acid).  It  is  usually  employed  in  the 
form  of  Volkmann's  thymol  solution: 

Thymol i.o 

Alcohol    20.0 

Glycerin 20.0 

Mix  well  and  add 

Water 1000.0 

This  may  be  used  as  either  a  spray  or  lotion.  When 
phenol  or  sublimate  solutions  irritate  (especially  causing 
eczema)  this  may  be  used  instead. 

ANURIA:   POSTOPERATIVE. 

Possibly  the  best  remedy  for  suppression  of  urine 
after  operation  is  sulphate  of  sparteine,  regardless  of  the 
cause  of  anuria.  Most  of  these  cases  are  due  to  a  pre- 
existing nephritis  from  sepsis,  cholemia,  etc.,  and  should 
then  be  treated  with  this  remedy  before  operation  as  well 
as  after,  because  the  anuria  is  to  be  anticipated,  regardless 
of  the  kind  of  anesthetic  used,  chloroform  being  appar- 
ently as  dangerous  in  this  condition  as  ether  or  the  newer 
hyoscine-morphine-cactin  combination . 

Every  patient  affected  by  sepsis  or  cholemia  should  there- 
fore be  examined  for  albuminuria,  and  if  this  be  found, 
operation  should  be  postponed  a  few  days,  if  possible, 
until  the  sparteine  be  given.  But,  unfortunately,  patients 
suffering  from  obstruction  of  the  common  bileduct,  from 
strangulated  hernia,  from  retention  of  urine,  etc.,  cannot 
be  held — so  here  the  surgeon  must  operate  and  do  the  best 
he  can  to  prevent  anuria  by  immediate  resort  to  proper 
therapeutic  measures.  For  if  vigorous  treatment  is  not 
instituted  the  patient  may  do  well  for  a  few  hours,  then 
become  restless,  listless  and  slightly  feverish,  later  develop- 
ing a  stupor  which  speedily  passes  into  coma,  ending 


ANUS:     DISEASES  OF  75 

in  death  from  uremia,  even  though  anuria  may  not  be 
complete;  in  the  more  pronounced  type  total  suppression 
of  urine  being  noted. 

The  first  thing  to  do  is  to  give  plenty  of  normal  salt 
solution  under  the  skin;  one  liter  (a  quart)  being  injected 
every  eight  hours;  next,  to  administer  sulphate  of  spar- 
teine,  a  drug  which  increases  the  blood-pressure  and  acts 
as  a  powerful  diuretic.  Within  thirty  minutes  its  full 
action  will  begin,  and  the  slow  and  full  pulse  indicates 
persistence  of  its  effect  from  four  to  six  hours,  at  the 
end  of  which  time  the  dose  is  to  be  repeated.  The  amount 
to  be  given  is  30  to  50  milligrams  (from  one-half  to  three- 
fourths  of  a  grain)  hypodermically.  The  patient  should 
be  encouraged  to  drink  as  much  water  as  possible. 

ANUS:    DISEASES  OF. 

It  is  peculiar  that,  accessible  as  is  the  lower  four  inches 
of  the  rectum,  its  diseases  should  be  so  ignored  by  the 
general  practician.  Even  the  anus,  plainly  visible  to  simple 
inspection,  is  seldom  examined,  although  complained 
about.  Prescriptions  should  never  be  given  'until  ocular 
evidence  of  the  existing  malady  has  been  obtained;  an 
operable  cancer  might  be  ignored  until  too  late  to  save  life. 
The  four  symptoms:  pain,  protrusion,  hemorrhage  and 
discharge,  may  be  present  in  so  many  conditions  that  to 
"guess"  is  almost  criminal. 

Of  the  troubles  common  to  the  anus  the  most  likely 
to  be  found  is  hemorrhoids  (which  see). 

Abscess  of  Anus. — A  superficial  abscess  may  form  in 
one  of  the  small  glands  around  the  anus,  as  well  as  from 
ulceration  of  a  small  external  hemorrhoid,  and  rarely  from 
trauma  to  the  cellular  tissue  surrounding  the  anus.  On 
account  of  the  tendency  of  pus  to  burrow  at  this  particu- 
lar part  incision  should  be  made,  under  cocaine  injected 
well  behind  the  little  abscess,  so  that  as  soon  as  the  pus 


76  SURGICAL  THERAPEUTICS 

is  expressed  search  may  be  made  with  a  probe  to  ascer- 
tain whether  the  trouble  be  simply  a  localized  abscess 
or  the  lower  end  of  (a)  an  ischiorectal  abscess,  or  (b)  a 
forming  fistula  of  the  rectum. 

Artifical  Anus. — This  must  be  made  whenever  the 
natural  outlet  is  closed  by  cancer,  tumor  or  inoperable 
stricture.  It  is  made  by  opening  the  abdomen  by  a  two- 
inch  cut  over  the  sigmoid,  drawing  a  loop  of  gut  out,  pack- 
ing gauze  into  the  cut  around  the  bowel  and  opening 
the  intestine  three  or  four  days  later,  after  the  peritoneal 
opening  has  been  closed  by  adhesions.  In  some  cases  a 
complete  colostomy  is  to  be  made. 

Cancer  of  the  Anas. — Cancer  of  the  anus  is  not  so 
common  as  that  of  the  rectum,  but  is  susceptible  of  com- 
plete cure  if  recognized  early.  Two  methods  of  removal 
are  subject  to  choice:  (i)  excision  and  suturing,  with 
rectal  packing  for  some  days;  (2)  very  deep  destruction  of 
infected  and  adjacent  tissue  with  the  Paquelin  cautery. 
The  latter  is  less  painful  and  gives  better  ultimate  results. 
It  should  be  used  with  the  patient  in  full  surgical  narcosis, 
with  the  sphincter  thoroughly  dilated;  and  the  rectum  must 
be  packed  tightly  with  iodoform  gauze,  which  is  to  be 
removed  in  forty-eight  hours. 

Chancre  of  Anas. — This  affection  occasionally  comes 
under  the  observation  of  the  surgeon  (in  Chinese  coolies, 
for  instance).  It  is  to  be  treated  the  same  as  the  initial 
lesion  of  syphilis  elsewhere. 

Fissare  of  Anas. — Obstinate  cases  of  fissure  of  the 
anus  which  resist  all  other  forms  of  treatment  may  be 
permanently  relieved  by  simply  cutting  through  the  external 
sphincter  under  local  anesthesia.  The  incision  must  be 
directly  in  the  line  of  the  fissure.  After  division  of  the 
muscle  the  rectum  should  be  packed  with  iodoform  gauze 
for  two  days;  then  the  wound  should  be  loosely  packed 
once  every  twenty-four  hours  for  four  or  five  days,  after 


ANUS:     DISEASES  OF  77 

the  bowels  have  moved  and  the  sigmoid  and  rectum  have 
been  washed  out  with  tepid  water. 

Before  resorting  to  radical  operation,  palliative  meas- 
ures should  always  be  tried,  first.  The  most  important 
thing  is  a  laxative  diet,  and  soft  bowel-movements  must  be 
secured  by  mild  cathartics,  if  necessary.  On  retiring  each 
night,  there  should  be  an  injection  of  an  ounce  of  olive 
oil,  to  be  retained  until  morning,  which  aside  from  its 
local  beneficial  action  will  secure  a  soft  movement.  Next 
in  importance  to  the  regulation  of  the  bowels,  is  that  strict 
cleanliness  should  be  maintained,  by  bathing  the  anus 
night  and  morning,  and  also  after  each  dejection,  with 
hot  water.  The  parts  should  afterward  be  dried  with  a 
sterilized  piece  of  gauze,  and  a  pad  of  the  same  material 
placed  over  the  anus  and  kept  in  place  with  a  T-bandage. 
The  fissure  itself  may  be  burned  >once  a  week  with  stick 
nitrate  of  silver.  It  seems  to  act  like  a  charm  in  allaying 
the  painful  symptoms,  and  often  a  few  applications  will 
prove  sufficient. 

Non-operative  treatment  means  merely  to  give  laxa- 
tives and  to  burn  thoroughly  the  fissure  with  pure  carbolic 
acid.  Next  day  it  is  well'  to  begin  the  use  of  glycerin 
suppositories  containing  5  percent  of  iodoform.  In  a  few 
minutes  a  free  and  painless  bowel-movement  will  occur. 
The  suppository  may  be  used  every  day.  An  old  remedy 
was  a  teaspoonful  of  sulphur  at  bedtime  and  by  its  mild 
laxative  effect  it  certainly  did  much  good.  It  may  be 
combined  with  powdered  cinnamon  to  correct  the  smell 
and  taste. 

This  little,  painful,  irritating  crack  in  the  .skin  and 
mucous  membrane  of  the  anal  verge  is  generally  due  to 
the  passage  of  hardened  feces.  Simple  dilation  of  the 
sphincter,  burning  the  fissure  thoroughly,  and  maintenance 
of  subsequent  laxity  of  the  bowels  usually  suffice.  A 
soothing  ointment  may  be  ordered. 


78  SURGICAL  THERAPEUTICS 

Fistula  of  Antis. — When  fistula  of  the  rectum,  com- 
monly called  fistula  in  ano,  is  found,  a  probe  should  be 
run  through  it  into  the  gut  and,  with  local  anesthesia,  the 
sphincter  ani  divided.  The  wound  must  be  repacked 
daily  until  healed  from  the  bottom.  If  slow  in  granu- 
lating, balsam  of  Peru  may  be  used  to  stimulate  rapid 
healing. 

Imperforate  Anus. — Babies  are  sometimes  born 
with  no  connection  between  anus  and  sigmoid;  and  even 
the  anus  is  missing  in  the  worst  cases.  If  the  obstruc- 
tion be  a  mere  membranous  septum  it  may  be  divided 
by  the  knife,  cutting  toward  the  coccyx.  If  there  be  a 
long  distance  between  anus  and  sigmoid  the  child  must 
be  chloroformed  and  careful  dissection  made,  upward 
and  slightly  to  the  left,  in  the  hope  of  opening  into  the 
rectum  or  sigmoid;  if  found  the  wound  is  to  be  tamponed 
with  gauze  for  three  days;  if  not  found,  the  peritoneum 
may  be  opened  and  the  sigmoid  brought  down  to  the 
anus  and  sutured  there  if  possible.  When  this  cannot 
be  done  the  wound  must  be  tamponed  and  an  artificial 
anus  made.  In  cases  where  no  anus  is  present,  inguinal 
colostomy  is  the  only  treatment!  It  is  not  a  serious  opera- 
tion. 

All  operators  now  agree  with  Hunter  on  the  follow- 
ing propositions:  (i)  An  operation  should  always  be 
performed,  and  performed  without  delay.  (2)  If  there 
be  any  chance  of  establishing  an  opening  at  the  normal 
site  of  the  anus,  the  surgeon  should  at  first  direct  his  atten-. 
tion  to  this  procedure.  (3)  The  use  of  a  trocar  as  an 
aid  in  finding  the  rectal  pouch  before  or  after  incision 
through  the  perineum  is  not  sanctioned  by  modern  sur- 
gical authority.  (4)  The  results  of  attempts  to  estab- 
lish an  outlet  for  an  imperforate  rectum  through  the  peri- 
neum are  not  favorable  as  regards  the  production  of  a 
useful  anus.  (5)  In  case  of  failure  to  establish  a  new 


ANUS:     DISEASES  OF  79 

anus  in  the  anal  region,  colostomy  should  at  once  be  per- 
formed. (6)  In  the  formation  of  an  artificial  anus  the 
left  groin  is  the  best  site  for  the  operation.  (7)  Attempts 
at  establishing  an  anus  in  the  anal  region  after  a  colostomy 
are  attended  with  great  danger,  and  are  generally  unsuc- 
cessful. 

Prolapse  of  Anus. — Protrusion  of  the  rectum  (or  of 
its  mucous  membrane)  must  be  treated  by  returning  it 
again  and  again  within  the  sphincter,  following  each  time 
with  an  astringent  injection.  If  this  does  not  cure,  the 
sphincter  may  be  dilated  and  several  lines  burned  into 
(but  not  through)  the  mucous  membrane  parallel  with 
the  long  axis  of  the  gut;  a  Paquelin  cautery  being  used, 
with  complete  chloroform  or  hyoscine-morphine  narcosis. 
In  the  worst  cases  resection  is  necessary,  but  it  is  a  very 
serious  operation,  since  the  peritoneum  is  to  be  opened. 
Ventral  fixation  of  the  sigmoid  (colopexy)  is  preferred 
by  some  proctologists. 

Pruritus  Ani. — Nearly  all  cases  of  persistent  itching 
of  the  anus  may  be  traced  to  one  of  these  causes:  (i) 
The  most  common  is  superficial  ulceration  or  abrasion 
of  the  anal  canal.  (2)  Next,  catarrhal  diseases  of  the 
rectal  mucosa  which  cause  discharge  from  the  anus.  (3) 
External  hemorrhoids  or  skin-tags  which  prevent  proper 
cleansing  of  the  parts.  (4)  Small  polyps  of  the  anal 
canal,  protruding  internal  hemorrhoids,  prolapse,  fis- 
sures, etc.  The  treatment  consists  (in  addition  to  remov- 
ing the  cause)  in  restoring  the  altered  perianal  skin  to 
the  normal.  For  this  purpose  nitrate  of  silver  followed 
by  citrine  ointment  are  the  best  applications.  Pruritus 
is  also  caused  by  the  irritating  discharges  from  long- 
retained  fecal  accumulations  in  the  cecum  or  colon.  In 
children  the  trouble  often  arises  from  the  presence  of 
seat-worms,  which  may  be  remedied  by  the  injection, 
three  times  a  week,  of  infusion  of  quassia. 


80  SURGICAL  THERAPEUTICS 

AORTTTIS,  ACUTE 

Inflammation  of  the  arteries  is  not  perhaps  of  so  much 
interest  to  surgeons  as  is  phlebitis,  yet  it  is  occasionally 
encountered.  Of  all  arteries  the  aorta,  particularly  its 
arch,  is  the  most  subject  to  pathologic  changes.  This 
is  due  to  the  fact  that  the  first  part  of  the  aorta  has  no 
sheath,  and  the  blood  forced  against  the  walls  at  each 
systole  acts  as  a  constant  irritant  to  the  coats  at  that 
point.  There  are  also  such  predisposing  diseases  as  rheu- 
matism, typhoid  fever,  scarlet-fever,  smallpox,  puerperal 
diseases,  the  grippe,  tuberculosis  and  syphilis,  which 
produce  an  alteration  in  the  walls  of  the  aorta.  The 
symptoms  are  pain  in  the  aortic  arch,  or  a  substernal 
soreness  or  tenderness.  Dyspnea  is  marked,  and  peculiar 
in  that  it  continues  both  with  inspiration  and  expiration. 
A  diagnosis  is  seldom  made,  and  according  to  Anders 
cannot  be  established  with  any  absolute  certainty.  The 
treatment  indicated  is  absolute  rest,  cold  to  the  chest, 
sedatives  to  quiet  the  heart,  and  restriction  of  diet.  As 
a  rule  diagnosis  is  made  after  death. 

APPENDICITIS 

Inflammation  of  the  vermiform  appendix  has  been 
variously  called  "echyaditis,"  " epityphlitis "  and  "appen- 
dicitis." By  common  usage  the  last  name  has  become 
standard,  though  not  constructed  to  suit  philologists. 
The  appendix  itself  is  named,  in  full,  appendix  caeci 
vermiformis. 

Strictly  speaking,  perhaps,  appendicitis  is  always  a 
surgical  disease,  and  the  infected  part  should  be  removed 
within  the  first  few  hours  after  active  inflammatory 
changes  begin.  But,  there  are  some  people  who  will  not 
consent  to  operative  treatment  "as  soon  as  the  diagnosis 
is  made;"  there  are  some  doctors  who  will  not  operate 
themselves,  yet  who  are  so  situated  that  a  competent  sur- 


APPENDICITIS  81 

geon  cannot  be  gotten  to  the  charity  patient  far  away 
from  city  or  town.  What  is  to  be  done  in  such  cases? 

First,  Bowel-Evacuation. — Long  experience  has  con- 
vinced me  that  thorough  purgation  does  no  harm,  Ochsner 
and  others  to  the  contrary  notwithstanding;  indeed  it 
does  much  good  if  purgation  can  be  secured  by  some  agent 
which  will  not  produce  vomiting.  Therefore,  to  patients 
who  are  not  to  be  subjected  to  immediate  operation  I 
give  a  good  dose  of  Abbott's  saline  laxative,  repeated  in 
four  hours,  if  the  results  are  not  satisfactory.  A  small 
enema  sometimes  is  useful;  but  care  must  be  taken  not  to 
distend  the  colon.  Late  in  the  disease  olive  oil  is  useful. 

Second,  Pain. — For  the  control  of  pain  sulphate  of 
codeine  may  be  used,  guardedly;  any  opiate  produces  a 
tendency  to  nausea — and  vomiting  is  one  of  the  most 
distressing  (and  sometimes  dangerous)  symptoms  of 
the  disease.  Three  centigrams  (one-half  grain)  of  phos- 
phate of  codeine  may  be  given  hypodermically  at  any 
time  when  the  pain  is  intense;  or  the  same  quantity  of 
the  sulphate  may  be  left  in  pill-form  to  be  given  every  three 
or  six  hours,  by  mouth,  as  needed;  as  little  as  possible 
being  given.  Morphine  costs  less,  but  may  kill  the  patient; 
codeine  is  cheaper  than  a  coffin.  Hyoscyamine  is  espe- 
cially effective  when  the  pain  is  due  to  muscular  spasm; 
given  to  full  effect. 

Third,  Fever. — In  uncomplicated  appendicitis  the  tem- 
perature seldom  runs  above  100°  or  ioi°F.;  hence  "fever 
medicine"  is  not  often  required.  When  the  tempera- 
ture goes  above  io2°F.  a  small  dose  of  acetanilid  will 
cause  it  to  drop  to  about  normal  for  some  hours  while 
it  relieves  the  pain  and  nervousness;  one-half  gram  (8 
grains)  may  be  given  in  one  dose,  if  there  is  no  decided 
weakness  of  the  heart.  Aconitine  may  be  given,  if  pre- 
ferred, until  the  temperature  and  pulse  drop  to  the 
required  degree. 


82  SURGICAL  THERAPEUTICS 

Fourth,  Vomiting. — This  frequently  is  an  early,  per- 
sistent and  aggravating  feature  of  appendicitis  of  severe 
type,  and  is  indicative  of  oncoming  sepsis;  when  black- 
vomit  appears  the  patient  generally  dies  of  acute  sepsis 
(commonly  called  "diffuse  peritonitis")-  For  its  pre- 
vention three  things  are  necessary:  (a)  cleaning  out  the 
intestinal  canal;  (b)  perfect  quietude;  (c)  abstinence  from 
food  and  drink.  For  the  first  forty-eight  hours  it  is  best 
to  withhold  all  food  by  the  stomach  (rectal  feeding  may 
be  instituted  every  six  hours  with  patients  extremely 
weak),  and  give  as  little  water  as  possible.  The  pleading 
for  "a  little  ice  in  the  mouth"  must  not  be  heeded — if 
permitted  it  surely  will  lead  to  vomiting.  After  the  first 
two  days,  if  vomiting  does  not  occur,  the  amount  of  water 
by  stomach  may  be  increased  and  liquid  diet  carefully 
begun.  When  vomiting  persists  food  must  be  abandoned 
and  water  by  mouth  refused — thirst  being  overcome  by 
enemas  of  not  more  than  six  ounces;  if  it  becomes  alarm- 
ing one  milligram  (gr.  1-60)  of  salicylate  of  eserine  may 
be  given  hypodermically  every  two  hours,  four  times.  An 
oxgall  enema  will  help  to  turn  the  peristaltic  wave  down- 
ward. 

Fi/th,  Distension. — To  prevent  this  the  saline  laxative 
may  be  given  every  morning,  guardedly;  there  need  be 
no  hesitancy  on  account  of  possible  leakage  through  a 
perforation,  as  peristalsis  alone  will  never  force  feces 
through  a  hole  in  the  appendix;  and  it  does  not  to  any 
serious  degree  prevent  the  formation  of  adhesions,  the 
protective  barrier  against  general  infection.  But  when 
distention  is  great  the  ice-bag  may  be  used — or  hot  fomen- 
tations, if  they  give  more  comfort  to  the  patient,  as  is 
frequently  the  case.  Local  use  of  Crede's  ointment, 
mud-glycerin  poultices,  etc.,  does  no  good  except  to  make 
the  people  think  "there's  somethin'  doin'  ";  but  a  few 
drops  of  oil  of  turpentine  dissolved  in  olive  oil  and  thrown 


APPENDICITIS  83 

up  in  the  colon  sometimes  does  good;  and  if  the  disten- 
sion be  due  to  gas  in  the  colon  an  alum  enema  is  of  great 
service. 

Sixth)  Tumor. — In  a  large  proportion  of  cases  a  mass 
can  be  felt  in  the  region  of  the  appendix.  It  means  per- 
foration of  the  wall  of  the  appendix — the  presence  of 
pus — and  is  a  positive  indication  for  abdominal  section. 
If  radical  operation  is  refused  and  the  abscess  is  inclined 
to  open  externally,  poultices  may  be  applied  to  assist, 
and  simple  incision  made  as  soon  as  possible. 

A  large  proportion  of  cases  which  ought  to  be  sub- 
jected to  operative  treatment  must  be  taken  through  the 
attack  safely  without  it;  but  it  is  the  duty  of  every  doctor 
to  explain  the  dangers  to  patient  and  friends,  and  to  insist 
upon  operative  treatment  whenever  especially  indicated 
(as  the  formation  of  a  mass  in  the  cecal  region)  if  the 
services  of  a  fairly  competent  operator  can  be  secured. 

Appendix  in  a  Hernial  Sac. — Not  at  all  infre- 
quently an  appendix  may  be  found  in  a  hernial  sac;  and 
like  the  gut  it  may  become  strangulated  and  gangrenous. 
It  should  always  be  removed  when  in  an  incarcerated 
hernia,  as  the  macroscopic  examination  might  not  reveal 
the  existence  of  changes  so  serious  as  to  cause  perfora- 
tion if  it  were  returned  to  the  belly.  It  may  even  be 
found  in  the  scrotum.  In  one  of  my  operations  for 
scrotal  hernia  an  appendix  seven  inches  long,  adherent 
to  the-  testicle,  was  removed  from  the  scrotum  of  a  boy 
only  five  years  of  age. 

Appendicitis  in  Pregnancy. — What  shall  be  done 
in  a  case  of  appendicitis  occurring  in  a  woman  well 
advanced  in  pregnancy?  If  the  case  be  mild  it  may  be 
treated  by  medicines  alone;  if  severe,  there  need  be  no 
hesitancy  about  operation,  and  the  operation  should  be 
the  same  as  in  any  other  patient.  If  the  work  be  done 
under  hyoscine-morphine-cactin  anesthesia  (plus  a  little 


84  SURGICAL  THERAPEUTICS 

cocaine  for  the  skin  or  chloroform,  if  needed)  there  need 
be  little  fear  of  premature  labor.  The  uterus  is  simply 
held  to  the  left  side  of  the  belly  by  an  assistant  while  the 
appendix  is  removed  or  the  abscess  opened  and  packed. 
If  labor  does  appear  the  wound  should  be  well  protected 
and  supported  by  two  or  three  strips  of  adhesive  plaster 
and  a  wide  binder  firmly  applied. 

Colitis  after  Appendectomy. — When  discharging 
a  patient  operated  upon  for  appendicitis  the  surgeon 
should  invariably  explain  the  very  important  point  that 
after  removal  of  the  appendix,  symptoms  of  appendicitis 
sometimes  persist,  leading  the  patient  to  believe  that  the 
organ  has  not  been  extirpated.  These  are  generally 
due  to  a  colitis,  which  must  be  treated  by  high  irrigations, 
diet,  etc. 

Diffuse  Sapporative  Peritonitis  from  Appen- 
dicitis.— When  the  abscess  adjacent  to  the  gangrenous 
or  perforated  appendix  has  ruptured  and  the  pus  has 
become  disseminated  throughout  the  lower  part  of  the 
abdomen  and  pelvis,  the  incision  should  not  be  made  over 
the  site  of  the  original  abscess  (appendical  region)  but 
in  the  midline;  and  it  should  be  very  free:  three  to  six 
inches  in  length — indeed,  sometimes  from  the  pubes  to 
two  or  three  inches  above  the  umbilicus.  But  the  peri- 
toneum must  be  subjected  to  as  little  handling  as  pos- 
sible, rubbing  with  gauze  being  especially  injurious. 
The  best  management  seems  to  be  (a)  to  wash  out  the 
abdomen  and  pelvis  with  gallons  of  hot  saline  solution; 
(b)  remove  the  appendix  and  such  part  of  the  omentum 
as  seems  too  badly  infected  to  live;  (c)  again  wash  out 
the  belly  and  sponge  out  the  surplus  fluid;  (d)  close  the 
abdomen  without  drainage.  (Drained  patients  almost 
always  die.)  If  this  method  of  treatment  be  adopted 
within  seventy-two  hours  after  the  rupture  occurs,  a  large 
percent  of  cases  may  be  saved;  later  than  that  time  the 


APPENDICITIS  85 

prognosis  invariably  is  bad.  Operation  in  these  cases 
should  therefore  be  performed  as  soon  as  the  diagnosis 
is  made. 

Treatment  after  Appendectomy. — Treatment  after 
appendectomy  does  not  differ  from  that  after  any  other 
abdominal  section  if  the  belly  is  closed  save  in  that  a 
cathartic  should  not  be  given  until  seventy-two  hours  or 
more,  in  order  that  firm  adhesion  of  serosa  to  serosa  over 
the  site  of  removal  of  appendix  may  have  time  to  form; 
and  even  then  an  occasional  leakage  occurs.  But  when 
drainage  is  instituted  the  management  is  quite  different, 
locally.  In  applying  the  binder  after  the  operation,  and 
at  all  subsequent  dressings,  great  care  must  be  taken  that 
there  is  no  pressure  directly  over  the  site  of  drainage. 

Most  of  the  periappendiceal  abscesses  are  now  drained 
by  gauze,  so  the  only  thing  to  be  done  for  the  first  two  days 
is  to  change  the  cotton  and  outside  layers  of  gauze  as 
often  as  they  become  soiled.  When  fecal  fistula  is  present, 
this  may  be  rather  often,  as  the  smell  is  quite  offensive, 
particularly  in  hot  weather.  The  gauze  next  to  the  wound 
may  be  changed  as  early  as  the  fourth  day  and  it  is  safe  to 
remove  all  of  the  packing  on  the  fifth  day  (though  a  week 
is  better).  In  removing  the  packing  the  last  piece  put 
in  should,  if  possible,  be  the  first  removed,  but  often  it 
is  impossible  to  tell  which  is  last,  and  frequently  the  whole 
mass  comes  away  together  when  the  opening  is  large. 
Through  an  inch  incision  it  is  best  to  draw  each  strand  sep- 
arately and  slowly,  particularly  those  portions  lying  next 
to  the  intestines  and  omentum — i.  e.,  nearest  the  midline. 
In  rare  cases  as  late  as  the  sixth  day  the  adhesions  will 
be  so  weak  that  omentum,  and  still  more  rarely  intestine, 
will  follow  the  last  strip  of  gauze;  in  which  case  the  pro- 
truding mass  must  be  quickly  pushed  back  into  the  belly 
and  fresh  sterile  gauze  crowded  down  upon  it,  and  this 
should  then  not  be  disturbed  for  three  or  four  days. 


86  SURGICAL  THERAPEUTICS 

Under  no  circumstances  should  the  cavity  left  on  re- 
moval of  the  gauze  be  washed  out  with  peroxide  or  other 
solution,  for  some  small  opening  into  the  general  peritoneal 
space  may  be  present  through  which  fatal  infection  might 
occur  if  fluid  were  poured  in.  All  that  is  needful  is  to  clean 
out  the  pus,  feces,  etc.,  by  means  of  pledgets  of  absorbent 
cotton  on  forceps  or  wooden  toothpicks.  When  satisfac- 
torily cleaned,  without  any  rubbing  or  pushing,  the  cavity 
is  to  be  lightly  packed  with  gauze  and  the  superficial  anti- 
septic pad  applied. 

ARTERIAL  DISEASE 

Arteritis. — Acute  inflammation  of  an  artery  is  always 
a  local  trouble,  usually  dependent  upon  trauma  and 
always  upon  infection;  it  may  originate  from  a  septic 
embolus,  and  a  thrombus  may  lead  to  ulceration,  each 
with  formation  of  pus. 

Socalled  chronic  arteritis '  (or  endarteritis)  is  probably 
not  an  inflammation  at  all — an  arterial  sclerosis,  result- 
ing in  a  peculiar  condition  known  as  atheroma,  or  to 
atheromatous  changes  in  the  vessels,  particularly  of  the 
aged.  (See  "Atheroma.") 

Occasionally  following  thrombosis  there  is  great  inflam- 
matory thickening  of  the  endothelium,  leading  to  per- 
manent obliteration  of  the  artery:  arteritis  obliterans. 

There  is  no  treatment. 

Wotmds  of  Arteries. — When  one  of  the  smaller 
arteries  is  cut  or  torn  it  must  either  be  ligated,  twisted 
or  obliterated  by  pressure.  But  if  in  the  course  of  an 
operation  a  very  important  vessel  like  the  femoral,  axil- 
lary or  internal  carotid  be  cut  into,  unless  completely 
severed,  it  should  be  repaired  by  fine  catgut  stitches 
through  adventitia,  musculosa  and  intima,  all  knots  being 
upon  the  outside.  Then  when  it  is  seen  there  is  no  leak- 
age, the  sheath  of  the  vessel  must  be  sutured  carefully 


ARTIFICIAL  RESPIRATION  87 

over  the  point  of  junction  and  the  wound  closed  with 
a  firm  bandage.  If  asepsis  has  been  perfect,  healing  may 
be  obtained;  if  not,  secondary  hemorrhage  is  likely  to 
occur  and  must  be  met  by  temporary  firm  pressure  by 
the  nurse  and  prompt  ligation  by  the  surgeon. 

ARTHRITIS 

Arthralgia. — Pain  in  a  joint  may  be  due  to  (i) 
gout,  (2)  rheumatism,  (3)  syphilis,  (4)  synovitis,  or  (5) 
arthritis.  The  last  three  belong  to  surgery.  (See 
"Syphilis,"  "Synovitis"  and  "Joints.") 

Arthritis  Deformans  Improved  by  X-Ray* — Cases 
of  arthritis  deformans  may  sometimes  be  successfully 
treated  with  the  x-ray.  The  exposures  are  made  three 
times  a  week,  with  about  one  milliampere  of  primary  cur- 
rent for  fifteen  minutes.  Internal  treatment  and  massage  are 
also  to  be  employed.  The  method  seems  to  be  a  valuable 
one,  the  rays  stimulating  the  metabolism  of  the  affected 
joints.  This  should  be  taken  advantage  of  and  mas- 
sage and  passive  movement  added  to  assist  in  the  removal 
of  the  exudate. 

Arthropathy* — This  is  a  peculiar  disease  of  the  joints 
("Charcot's  joint"),  which  occurs  in  the  early  stages  of 
locomotor  ataxia.  It  speedily  destroys  the  joint,  although 
it  is  painless  and  progresses  without  inflammation. 
Hydrarthrosis  and  swelling  are  the  two  prominent  symp- 
toms. It  is  rare  and  affects  only  large  articulations.  It 
must  be  differentiated  from  tuberculosis,  which  can  be 
cured;  this  affection  can  not.  In  spite  of  all  treatment 
the  joint  becomes  lax,  this  condition"  being  followed  by 
much  distortion;  eventually  some  patients  have  dimin- 
ished range  of  motion,  while  others  have  excessive  motion. 

ARTIFICIAL  RESPIRATION 
Artificial    Respiration     of    the    Newly    Born. — 

Seize  the  buttocks  in  the  left  hand,  shoulders  and  neck 


88  SURGICAL  THERAPEUTICS 

in  the  right,  with  face  up;  bring  head  and  feet  together, 
compressing  the  thorax,  then  bend  the  child  backward 
to  form  an  arch,  thus  expanding  the  thorax;  after  five 
or  six  such  movements  turn  the  baby  over  and  spank  it 
sharply,  which  generally  is  followed  by  a  gasp;  if  not, 
turn  into  first  position  and  repeat  the  bending  forward 
and  backward.  Next,  if  unsuccessful,  the  child  may  be 
allowed  to  hang  with  its  head  directly  downward  and 
given  two  or  three  vigorous  shakes  to  dislodge  mucus 
from  its  throat,  then  brought  up  into  first  position,  dashed 
with  a  little  cold  water,  and  respiratory  movements  be 
again  instituted.  Attempts  to  cause  voluntary  respira- 
tion should  not  be  abandoned  for  not  less  than  fifteen 
minutes.  As  a  last  resort  the  lungs  may  be  inflated  by 
blowing  forcibly  into  the  babe's  mouth. 

Artificial  Respiration  of  Adults. — In  drowning,  the 
water  should  first  be  removed  by  inverting  or  shaking  or  roll- 
ing the  victim  on  a  barrel;  then  proceeding  as  in  chloroform 
narcosis.  With  the  patient  upon  his  back,  and  head  low- 
ered to  45  degrees,  if  possible,  the  bare  chest  is  seized  in  the 
two  hands  at  the  lower  ribs,  with  thumbs  meeting  below  the 
ensiform.  Then  firm  pressure  is  made  inward  and  upward 
to  compress  the  lower  part  of  the  thorax  to  the  utmost 
possible  extent;  then  pressure  is  gradually  relaxed,  allow- 
ing the  chest  to  expand.  After  two  or  three  seconds  this 
is  repeated.  Again  and  again  this  movement  is  carried 
on,  with  clock-work  regularity — not  hurriedly  and  excitedly, 
but  cooly,  deliberately — about  twenty  times  to  the  minute. 
Slapping  the  chest  is  not  to  be  permitted,  as  it  may  paralyze 
a  weak  heart  just  beginning  to  throb. 

This  artificial  respiration  usually  will  resuscitate  the 
patient  in  five  to  fifteen  minutes,  but  must  never  be  aban- 
doned until  at  least  an  hour  of  hard  work  has  elapsed. 
One  case  is  on  record  in  which  life  was  saved  by  four  hours' 
efforts. 


ASCITES  89 

After  the  patient  has  begun  to  breathe  he  must  be 
watched  for  some  time,  and  an  occasional  artificial  expira- 
tion be  induced  if  respirations  are  shallow  or  inclined 
to  stop  altogether.  Generally,  as  soon  as  redness  returns 
to  the  face,  it  is  safe  to  relax  vigilance.  But  some  indi- 
viduals (notably  hysterical  women)  exhibit  an  aggravating 
tendency  to  "hold  the  breath",  particularly  in  asphyxia, 
in  morphine  narcosis  and  in  excess  of  chloroform,  watching 
for  many  hours  being  required. 

ASCITES 

i 

Abdominal  dropsy  is  most  conspicuous  in  cirrhosis  of 
the  liver,  in  which  case  it  is  a  clear,  yellow,  thickish  fluid 
which  coagulates  on  standing.  When  accompanying  kid- 
ney-lesions it  contains  urea.  If  due  to  carcinoma  it  is 
bloody  or  turbid  and  contains  shreds.  In  peritoneal  tuber- 
culosis it  is  like  water.  When  there  has  been  rupture  of 
the  chyle-duct  it  is  whitish  and  contains  chyle.  From 
papilloma  of  the  ovary  it  is  like  that  of  cancer.  In  heart- 
lesions  it  is  associated  with  general  anasarca  or  at  least 
swelling  of  the  legs. 

Therapeutic  measures  directed  to  the  hydrops  alone 
seldom  are  indicated.  The  proper  treatment  invariably 
is  to  discover  the  cause  and  apply  appropriate  remedies 
or  institute  proper  operative  measures,  such  as  the  Talma- 
Morrison  operation  for  cirrhosis  of  the  liver,  simple  abdomi- 
nal section  for  tuberculous  peritonitis,  excision  of  papil- 
loma, and  so  forth. 

When  the  accumulation  is  so  great  as  to  interfere  with 
respiration  the  fluid  may  be  let  out  through  a  sterilized 
trocar  and  canula  (taken  right  out  of  the  boiler  and  not 
permitted  to  touch  anything  on  its  way  to  the  already 
cleaned  belly- wall).  It  should  be  done  under  cocaine 
anesthesia.  There  is,  generally,  entirely  too  little  pains 
taken  to  secure  ideal  asepsis  in  "tapping." 


90 

ASPIRATOR:  USE  OF 

At  one  time  aspiration  was  greatly  employed,  it  being 
thought  proper  to  withdraw  pus  (from  the  chest,  for 
example)  and  especially  serum  from  cavities  without  the 
introduction  of  air.  Since  it  has  been  learned  that  it  is 
not  air  but  dirt  which  changes  serous  contents  to  pus, 
and  that  free  drainage  is  better  than  closed,  the  method 
has  fallen  into  disuse.  A  small  aspirator  (or  large  hypo- 
dermic syringe)  still  is  used  to  withdraw  small  quantities 
of  fluid  for  diagnostic  purposes,  but  the  aspirator  as  a 
means  of  withdrawing  pathologic  accumulations  and  in- 
jecting antiseptic  substitutes  has  fallen  into  merited 
disuse. 

ATHEROMA 

This  is  a  fatty  degeneration  of  the  walls  of  the  arteries, 
generally  termed  " atheromatous  degeneration."  It  is 
of  great  importance  in  surgery,  because  when  present  in 
the  aged  it  is  a  contraindication  to  severe  operative  work. 

Sometimes  there  is  a  collection  of  soft  matter  external 
to  the  intima — said  to  be  the  result  of  a  localized  chronic 
arteritis,  but  it  is  doubtful  whether  it  has  any  relation  to 
pus;  yet  it  is  called  "atheromatous  abscess." 

When  this  "abscess"  breaks  through  the  intima  it 
constitutes  an  "atheromatous  ulcer." 

When  atheromatous  changes  have  occurred  the  most 
conspicuous  symptom  is  arcus  senilis:  a  whitening  of  the 
outer  rim  of  the  iris  (but  this  may  be  present  sometimes 
without  atheroma)  but  the  radial  artery,  as  well  as  others, 
may  be  felt  like  a  whip-cord:  hard  and  distinct  instead  of 
soft  and  compressible. 

In  very  old  patients  the  arteries  may  be  found  crumpled; 
irregular  and  hard;  the  "arteritis  deformans"  of  the  older 
pathologists — and  indeed  its  exact  pathological  character 
is  not  yet  clearly  known.  But  its  surgical  significance  is 


BACK:  SPRAINS  OF  91 

unmistakable:  when  persistent  it  is  a  sign-board  to  the 
surgeon — "Keep  Out!" 

AUTOSUGGESTION  AFTER  INJURY 

This  is  a  peculiar  mental  condition,  intimately  related 
to  self-hypnosis,  which  adds  much  to  the  suffering  of  the 
patient,  particularly  after  railway  accidents.  "The  mental 
spontaneity,  the  will  or  the  judgment,  is  more  or  less 
obscured  and  suggestions  become  easily  accepted.  Thus 
the  slightest  trauma  directed  to  any  member  may  become 
the  occasion  of  a  paralysis,  of  a  contracture  or  of  an 
arthralgia."  (Gould.)  It  has  also  been  called  "traumatic 
suggestion,"  but  the  term  "autosuggestion"  is  much  better, 
since  the  deformity,  pain,  etc.,  may  appear  without  any 
trauma,  merely  as  the  result  of  too  intense  introspection 
and  a  morbid  desire  for  sympathy.  Tonic  treatment, 
out-of-door  life,  change  of  scene,  severe  work  will  do  much 
to  correct  the  evil;  rarely  the  application  of  some  orthopedic 
apparatus  is  advisable,  but  as  a  rule  this  does  more  harm 
than  good  by  concentrating  attention  upon  the  presumably 
diseased  member. 

BACK:    SPRAINS  OF 

On  account  of  the  number  of  its  articulations  and  the 
strain  so  often  thrown  upon  it,  the  back  is  subject  to  many 
sprains.  These  may  vary  from  a  slight  twisting  to  an  al- 
most complete  dislocation.  As  it  is  impossible  to  tell  by 
examination  the  extent  of  injury  to  the  deep-lying  joint- 
structures  every  severe  injury  should  be  treated  as  if  it 
were  known  to  be  very  serious — until  time  demonstrates 
that  it  is  not.  An  injury  which  at  first  seems  to  be  trivial 
may  prove  to  be  extensive  laceration  of  the  spinal  ligaments; 
or  even  a  subluxation  of  the  vertebra?.  Sometimes  even 
in  dangerous  conditions  there  is  no  swelling  of  the  external 
parts.  Sprains  of  the  lumbar  region  may  be  accompanied 


92  SURGICAL  THERAPEUTICS 

by  hematuria;  but  this  is  but  transitory  and  need  not  occa- 
sion alarm.  The  treatment  should  consist  of  simple  rest 
in  bed  until  the  soreness  begins  to  disappear;  then -appli- 
cation of  a  stimulating  lotion,  like  the  chloroform  liniment 
of  the  U.  S.  Pharmacopeia.  In  case  of  possible  luxation 
a  radiograph  may  be  secured  as  soon  as  the  patient  is  able 
to  leave  his  bed. 

BACTERIA  OF  SURGERY 

The  word  bacteria  is  used  here  in  its  comprehensive 
sense,  that  is,  to  include  all  of  the  microscopic  plants  which 
are  disease-producing.  Many  of  these  microbes  are  bacilli. 
(The  bacillus  is  a  fungus — not  animal  or  "bug,"  although 
possessed  of  motion — belonging  to  the  schizomycetes.) 
Others  are  cocci:  coccus,  or  micrococcus — a  spherical  bac- 
terium, which  may  appear  isolated,  united  in  twos  (called 
diplococcus  then),  or  in  large  numbers;  when  in  groups, 
like  a  bunch  of  grapes,  they  are  designated  staphylococci, 
when  in  chains  or  chaplets,  they  are  termed  streptococci. 
A  few  belong  to  the  spirilli  (spirillum,  twisted-rod). 

Those  which  are  of  greatest  import  in  surgery  are  the 
following: 

Actinomyces  boms. — Found  in  actinomycosis  and  some- 
times in  tuberculous  sputum — probably  a  pleomorphic 
schizophyte. 

Anthrax  bacillus. — Occurs  in  the  blood  of  animals  and 
persons  infected  with  anthrax. 

Bacillus  aerogenes. — A  bacterium  found  in  the  intes- 
tine of  healthy  persons  which  may,  under  peculiar  circum- 
stances, get  into  the  cellular  tissues  and  cause  great 
swelling. 

Bacillus  coli  communis. — Occurs  in  the  air,  in  putre- 
fying infusions,  and  constantly  in  the  feces  of  healthy  human 
beings.  An  active  agent  in  the  production  of  appendicitis 
and  cholecystitis.  Is  also  called  bacillus  neapolitanus. 


BACTERIA  OF  SURGERY  93 

Bacillus  diphtheria. — Known  also  as  the  "Klebs- 
Loffler  bacillus."  Distinctive  of  diphtheritic  false  mem- 
branes. 

Bacillus  cedematis  tnaligni. — So  called  by  Koch;  the 
vibrion  septique  of  Pasteur.  The  peculiar  microorganism 
of  gangrenous  septicemia. 

Bacillus  of  Lustgarten. — A  supposititious  microorgan- 
ism of  syphilis. 

Bacillus  of  P/eiffer. — The  specific  microorganism  of 
epidemic  influenza  ("the  grippe"),  now  known  to  be  a 
pus-producing  germ. 

Bacillus  pneumonia. — The  presumed  causative  micro- 
organism of  croupous  pneumonia;  is  often  called  Fried- 
lander's  bacillus.  The  bacillus  is  now  known  to  be  pus- 
producing. 

Bacillus  prodigiosus. — Of  interest  on  account  of  its  use 
in  connection  with  the  streptococcus  erysipelatis  of  Feh- 
leisen  in  the  Coley  treatment  of  cancer. 

Bacillus  (or  leptothrix)  puerperale. — A  microbe  some- 
times found  in  puerperal  septicemia — claimed  by  Pasteur 
to  be  bacillus  anthracis. 

Bacillus  pyocyaneus. — The  distinctive  microorganism 
of  blue  '(or  green)  pus;  is  found  in  normal  sweat  some- 
times. 

Bacillus  pyo genes  fcetidus. — A  bacillus  obtained  from 
ischiorectal  abscess.  Of  little  pathogenic  significance. 

Bacillus  of  Schimmelbusch. — Found  in  the  necrotic  tissue 
of  no  ma,  cancrum  oris. 

Bacillus  septicus  sputigenus. — Now  generally  regarded 
as  the  cause  of  pneumonia;  found  constantly  in  the  healthy 
mouth;  also  in  the  pus  of  meningitis. 

Bacillus  of  senile  gangrene. — The  bacillus  of  Tricomi 
has  not  been  demonstrated  to  be  the  cause  of  senile  gan- 
grene, but  is  found  in  the  blood,  in  the  tissues  near  the 
line  of  demarcation,  in  the  subcutaneous  tissue  and  lymph- 


94  SURGICAL  THERAPEUTICS 

spaces  of  the  skin  and  in  the  discharge  from  gangrenous 
ulcers. 

Bacillus  of  smegma. — Always  present  in  the  smegma  of 
both  male  and  female. 

Bacillus  of  tetanus. — Is  also  called  bacillus  of  Nicolaier; 
it  is  derived  from  earth  and  horse-manure. 

Bacillus  tuberculosis. — The  well-proven  cause  of  pul- 
monary and  other  forms  of  tuberculosis;  Koch's  bacillus. 

Bacillus  typhi  abdominalis. — Is  also  called  bacillus 
typhosus  and  Eberth's  bacillus;  the  microorganism  of 
typhoid  fever. 

Bacillus  vulgaris. — Not  distinctly  proven  to  be  of  import 
in  surgery,  but  is  constantly  associated  with  putrefaction. 

Diplococcus  albicans  tardissimus. — A  microbe  identical 
morphologically  with  the  gonococcus,  but  more  adherent, 
forming  small  masses. 

Diplococcus  inter  cellular  is  meningitidis . — The  coccus 
found  in  the  exudates  of  cerebrospinal  meningitis;  also  pus- 
producing. 

Diplococcus  pyo genes  urea. — Found  in  purulent  urine; 
as  is  also  diplococcus  urea  trifoliatus. 

Gonococcus. — The  cause  of  "clap;"  also  called  Neisser's 
micrococcus,  or  micrococcus  gonorrhea. 

Micrococcus  cereus  albus. — Sometimes  present  in  acute 
abscesses. 

Micrococcus  cereus  flavus. — Found  in  the  lemon-yellow 
pus  of  certain  abscesses;  also  termed  staphylococcus  cereus 
flavus. 

Micrococcus  osteomyelitidis. — The  germ  found  in  pus 
of  acute  osteomyelitis — without  doubt  staphylococcus  pyo- 
genes  aureus  working  under  peculiar  environment. 

Saccharomyces  albicans. — The  microorganism  of  thrush 
and  rarely  of  vaginitis;  a  synonym  is  oidium  albicans. 

Saprogenic  bacteria. — Those  which  produce  putrefac- 
tion; cause  of  sapremia. 


BALANITIS  95 

Saprophytic  bacteria. — Saprophytes:  in  biology,  chloro- 
phylless  plants  which  derive  their  sustenance  from  decaying 
organic  matter;  high  fever  due  to  the  action  of  the  bacteria 
of  putrefaction  (as  in  blood  retained  in  utero)  is  now  said 
to  be  of  saprophytic  origin — or  sapremia.  Saprogenic  is 
perhaps  the  better  term  to  describe  these  germs.  Treat- 
ment will  be  discussed  elsewhere. 

Staphylococcus  epidermidis  albus. — The  microorganism 
of  the  white  pus  of  stitch-abscesses;  a  skin  coccus,  known 
also  as  micrococcus  pyogenes  albus  and  Staphylococcus 
Pyogenes  albus. 

Staphylococcus  pyogenes  albus. — The  peculiar  microbe 
of  white  pus. 

Staphylococcus  pyogenes  aureus. — Found  in  yellow 
"laudable"  pus;  occurs  in  boils,  wound  infections,  osteo- 
myelitis, ulcerative  endocarditis,  etc. 

Staphylococcus  pyogenes  citreus. — The  microbe  of  lemon- 
yellow  pus;  perhaps  but  a  variation  of  aureus. 

Streptococcus  pyogenes. — The  virulent  germ-poison  of 
erysipelas,  puerperal  sepsis  of  the  worst  form,  certain  types 
of  carbuncle  and  deep  cellular  inflammations;  also  known 
as  micrococcus  pyogenes. 

BALANITIS 

Inflammation  of  the  glans  penis.  It  is  also  sometimes 
named  balanoposthitis  because  the  prepuce  is  usually  in- 
flamed (posthitis)  at  the  same  time.  The  best  treatment  is 
to  bathe  the  part  two  or  three  times  a  day  with  liquor 
antisepticus.  The  menthol  compound  tablet  (A.  A.  Co.), 
dissolved  in  water,  makes  a  good  and  cheap  antiseptic 
lotion.  If  there  be  much  secretion,  borated  talcum  may 
be  used,  or  pure  boric  acid.  If  decomposition  of  smegma 
be  the  source  of  irritation  and  phimosis  prevents  the  needed 
oft-cleaning,  circumcision  must  be  done  and  antiseptics 


96  SURGICAL  THERAPEUTICS 

used  until  healing  is  perfect.     To  harden  the  glans  dilute 
bay  rum  or  other  alcoholic  application  may  be  used. 

BEDSORES 

A  bedsore  is  a  localized  necrosis  of  skin  and  subcu- 
taneous cellular  tissue,  due  to  an  anemia,  dependent  upon 
long-continued  pressure  and  low  vitality.  The  three  chief 
preventive  measures  are  (i)  cleanliness,  (2)  frequent  change 
of  position,  even  though  slight,  and  (3)  keeping  the  draw- 
sheet  free  from  wrinkles.  Two  teaspoonfuls  of  salt  to  a 
pint  of  whisky  makes  an  excellent  wash  to  use  at  places 
already  reddening.  A  very  good  combination,  used  in 
many  hospitals,  consists  of  one  ounce  of  powdered  alum, 
the  whites  of  four  eggs  and  two  ounces  of  spirit  of  camphor. 
This  is  to  be  used  only  for  prevention  of  the  sores.  After 
the  skin  is  broken  and  stinking  begins,  most  careful  atten- 
tion is  necessary  to  prevent  extensive  sloughing.  The 
sore  must,  first  of  all,  be  protected.  A  rubber  ring,  air- 
inflated,  may  be  so  placed  that  no  weight  comes  upon  the 
tissues  near  the  sore;  or  pillows  must  be  placed  above 
and  below  to  completely  remove  pressure.  The  sore  must 
be  covered  by  antiseptic  gauze;  best  dipped  in  a  solution 
made  by  triturating  equal  parts  of  camphor  and  phenol, 
with  oiled  silk  and  bandage  over  it,  if  it  can  be  applied. 
When  sinuses  form  they  must  be  widely  opened  and  treated 
with  the  camphophenolized  gauze.  As  the  patient  con- 
valesces the  surface  of  the  ulcers  may  be  cauterized  with 
nitrate  of  silver  if  they  are  sluggish  in  healing.  Probably 
iodoform  is  the  best  thing  to  promote  granulation  in  such 
cases. 

Prevention. — When  a  patient  is  to  be  in  bed  for  a 
long  time,  as  in  fracture  of  the  thigh,  great  care  must  be 
exercised  that  bedsores  do  not  form.  In  the  first  place, 
linen  draw-sheets  must  be  made,  sufficiently  large  that  they 
may  be  firmly  fastened  to  the  sides  of  the  bed  so  as  to  pre- 


BICHLORIDE  SOLUTIONS:     STRENGTH  OF          97 

vent  creases  or  wrinkles  forming  under  the  body — these 
and  dribbling  urine  being  the  most  frequent  causes.  When- 
ever the  sheets  become  soiled  by  urine,  feces  or  discharge 
from  a  wound,  they  must  be  changed.  As  soon  as  the 
slightest  redness  of  skin  is  observed  the  affected  surface 
must  be  rubbed  with  alcohol  (65 -percent)  and  dried  and 
then  carefully  anointed  with  glycerin;  twice  daily  at  least. 
Or  equal  parts  of  tincture  of  catechu  and  liquor  plumbi 
may  be  substituted  for  the  glycerin  if  that  causes  much 
smarting,  as  it  sometimes  does. 

BEE-STINGS 

For  the  poisoning  from  bee-stings,  bites  of  insects,  etc., 
aqua  ammonia  may  be  employed,  applying  it  on  a  little 
absorbent  cotton  over  the  congested  area.  It  may  be 
renewed  in  a  few  moments  when  evaporation  of  the  first 
application  has  occurred. 

BICHLORIDE    SOLUTIONS:    STRENGTH    OF 

Many  doctors,  and  most  hospitals,  make  solutions  of 
bichloride  of  mercury  entirely  too  strong  to  be  of  great 
value.  For  purposes  of  assisting  in  sterilization  of  hands 
and  field  of  operation  i  in  2000  is  decidedly  to  be  pre- 
ferred. It  is  sufficiently  germicidal  for  all  practical  pur- 
poses; anything  stronger — like  the  commonly  used  i  in 
1000  strength — so  affects  the  skin  that  the  deeper  micro- 
organisms escape;  and  after  a  few  minutes'  hard  work  they 
are  brought  to  the  surface  by  imperceptible  sweating. 
Most  surgeons,  too,  merely  wash  the  hands  in  the  subli- 
mate solution  instead  of  permitting  them  to  soak  for  two 
minutes,  by  the  clock.  During  severe  operations  the 
hands  should  be  often  immersed  in  the  sublimate  solution, 
and  rinsed  in  salt  solution  before  returning  to  the  wound, 
particularly  in  abdominal  work.  For  practical  purposes 
the  solution  should  be  prepared  at  time  of  operation. 


98  SURGICAL  THERAPEUTICS 

BLACK  EYE 

Ecchymosis,  following  a  blow  about  the  eye  or  temple, 
is  sometimes  very  annoying.  Circumstances  are  often 
such  that  it  is  necessary  to  absorb  the  blood  quickly  and 
to  disguise  the  extravasation  while  undergoing  the  heal- 
ing process.  Temporary  discolorations  of  the  skin  may  be 
disguised  by  the  application  of  grease,  paint,  or  collodion 
colored  by  means  of  a  little  carmine.  As  a  lotion  the  fol- 
lowing is  recommended:  Ammonium  chloride,  10;  alcohol, 
10;  water,  100.  Dilute  acetic  acid  may  be  substituted  for 
half  the  water  and  the  alcohol  may  be  replaced  with 
advantage  by  tincture  of  arnica  in  some  cases.  Another 
good  lotion  is:  Potassium  nitrate,  2;  ammonium  chloride, 
4;  aromatic  vinegar,  32;  water,  480. 

BLACK-VOMIT 

This  occurs  in  any  acute  sepsis,  like  that  following 
serious  infection  of  the  peritoneum,  that  which  is  such 
an  alarming  feature  of  yellow-fever,  etc.  Very  rarely 
it  may  be  arrested  (if  the  bowels  can  be  started  moving) 
by  the  exhibition  of  from  20  to  30  drops  of  the  fluid  extract 
of  adrue  (the  root  of  cyperus  articulatus:  antiemetic 
root;  not  official). 

BLADDER 

Atony, — In  this  trouble  there  is  inability  to  expel 
the  urine,  from  deficient  muscular  power.  Small  doses 
of  cantharidin  and  strychnine  may  be  given  in  the  hope 
of  increasing  tone,  but  in  many  cases  a  "catheter  life"  is 
inevitable.  Some  cases  have  been  greatly  benefited  by 
suprapubic  cystostomy  made  with  the  sole  object  of 
allowing  the  bladder- walls  to  contract  and  have  perfect 
rest  for  a  period  of  from  four  to  six  weeks,  when  the  open- 
ing is  allowed  to  close  by  granulation. 


BLADDER  99 

Catarrh  of  the  Bladder. — Following  an  acute 
inflammation  of  the  bladder  there  may  be  left  a  catar- 
rhal  condition  of  the  mucosa,  formerly  called  "chronic 
inflammation."  (See  "Cystitis.") 

Exstrophy. — Rarely  there  is  met  a  congenital  atesence 
of  the  anterior  wall  of  the  bladder  with  more  or  less 
deficiency  in  the  corresponding  part  of  the  abdomen. 
Repeated  plastic  operations  constitute  the  only  treatment. 

Hernia  of  Bladder. — In  operating  for  hernia,  and 
especially  the  direct  form,  the  surgeon  must  be  sure  to 
remember  that  the  bladder  may  be  in  the  sac;  and  if 
adherent  (as  is  often  the  case)  may  be  opened  instead  of 
the  peritoneum.  If  the  amount  of  bladder  implicated  is 
small,  or  if  it  is  a  postoperative  cystocele,  it  will  be  found 
growing  thicker  upward,  enveloped  in  fat,  and  this  thicker 
extension  will  be  discovered  to  be  the  bladder,  if  the  opera- 
tor is  fortunate.  When  the  prevesical  fat  is  detached 
the  bladder  appears.  In  case  of  doubt  the  bladder  can 
be  filled  with  fluid  and  the  effect  watched  on  the  sus- 
pected cystocele.  In  presence  of  a  diverticulum  or  a  stone 
in  the  hernia,  the  bladder  must  be  opened  and  resected; 
otherwise  the  bladder  is  to  be  reduced  unopened.  Unfortu- 
nately, however,  it  is  discovered  most  often  only  after  it 
has  been  opened — in  which  event  the  bladder-wall  must 
be  sutured,  a  permanent  catheter  inserted  and  the  her- 
niotomy  wound  drained. 

Inflammation  of  the  Bladder^Ah  irritable  deep 
urethra  or  ulcer  at  the  neck  of  the  bladder  closely  simu- 
lates inflammation  of  the  bladder;  comparatively  rare  is  a 
true  cystitis  (which  see). 

Inversion. — Cases  of  prolapse  of  the  bladder  through 
the  urethra  have  been  reported.  The  rational  treatment 
is  cystopexy. 

Irritable  Bladder. — A  constant  desire  to  urinate 
is  quite  frequently  met  with,  especially  in  women  well 


100  SURGICAL  THERAPEUTICS 

advanced  in  years.     It  is  often  very  hard  to  relieve.     The 
use   of   arbutin,   long-continued,   is  generally  effective. 

Nervous  Bladder. — Closely  allied  to  "irritable  blad- 
der" is  "nervous  bladder,"  a  condition  found  in  nervous 
persons  who  have  a  desire  to  pass  urine  at  brief  inter- 
vals, sometimes  almost  constantly;  yet  on  attempting  to 
do  so  they  are  unable  to  perform  the  act  perfectly,  so 
there  is  dribbling  at  the  close  and  a  burning  sensation 
which  might  lead  the  uninitiated  doctor  to  suspect  the 
presence  of  stone.  In  women  a  prolapse  of  the  bladder 
is  often  the  cause  of  this  suffering.  (See  "Cystocele.")  In 
most  cases  the  administration  of  elixir  of  the  bromide 
of  potassium  (a  teaspoonful  two  or  three  times  a  day) 
or  of  eight  centigrams  (one  grain)  of  arbutin  every  three 
or  four  hours  will  afford  temporary  relief.  The  per- 
sistent use  of  lithium  benzoate  in  doses  of  one  decigram 
(i  1-2  grains)  four  times  a  day  will  sometimes  lead  to 
very  gratifying  results.  Hyoscyamine  is  quickly  effective. 
Paralysis. — The  symptoms  are  much  like  atony — 
only  worse;  if  the  paralysis  is  limited  to  the  neck  of  the 
bladder  alone  there  is  incontinence  of  urine,  for  which 
practically  nothing  can  be  done;  if  it  involve  the  bladder- 
wall  there  will  be  retention  and  the  catheter  must  be 
used  every  six  hours.  In  some  cases  cystostomy  is  advis- 
able to  secure  perfect  relief  from  retention  wilh  its  con- 
stant danger  of  cystitis  and  pyelitis. 

Prolapse  of  Bladder. — Among  women  a  frequent 
source  of  complaint  is  "irritation  of  the  bladder" — cystitis, 
they  are  told  by  their  doctors  who  proceed  to  dope  them 
with  triticum,  hyoscyamus,  salol,  or  various  "proprietary 
remedies."  What  is  needed  in  many  cases  is  simply 
removal  of  urethral  caruncle,  prolapse  of  urethra,  or, 
generally,  cystocele.  It  is  so  easy  and  so  sure  to  make 
anterior  colporrhaphy  and  then  a  close  perineorrhaphy 
that  it  is  astonishing  why  doctors  do  not  more  frequently 


BLADDER  101 

try  it.  The  relief  afforded,  even  if  there  is  no  financial 
benefit,  is  sufficient  reward  for  the  extra  trouble. 

Speculated  Bladder. — Very  rarely  pouches  form 
between  hypertrophied  muscular  fibers.  Cystostomy  is 
sometimes  warranted. 

Stone  in  the  Bladder. — Small  stones  may  be  cured  by 
lithotripsy  (crushing)  and  irrigation.  Large  stones  must 
be  removed  by  operation.  Suprapubic  cystotomy  is  prefer- 
able. 

Treatment  after  Bladder  Operations. — Since  post- 
operative anuria  is  the  most  frequent  complication  it 
is  well  to  give  a  liter  (one  quart)  of  normal  salt  solution  by 
hypodermoclysis  immediately  after  the  patient  is  returned 
to  bed;  and  especially  so  if  there  be  much  shock. 

As  soon  as  possible,  too,  as  much  water  as  the  patient 
can  drink  should  be  given. 

When  suprapubic  cystotomy  has  been  done  the  urine  is 
usually  carried  away  by  a  long  rubber  tube,  but  there 
is  much  leakage  around  the  opening,  so  it  is  necessary  to 
change  the  gauze  two  or  three  times  a  day;  and  if  there  be 
much  irritation  of  the  bladder  (or  cystitis)  it  is  best  to  also 
wash  out  the  bladder  at  the  same  time,  using  a  saturated 
solution  of  boric  acid. 

The  irritation  of  skin  is  not  as  serious  as  in  perinea! 
cystotomy  but  sometimes  requires  careful  attention. 

When  the  bladder  has  been  sutured  and  the  abdominal 
incision  closed  the  wound  requires  no  attention  until  the 
time  to  remove  the  sutures  (ninth  or  tenth  day)  provided 
the  gauze  does  not  become  soiled  with  urine.  But  as  it  is 
necessary  to  use  the  catheter  every  four  hours  for  a  week, 
in  such  cases,  the  dressings  usually  become  sufficiently 
infected  to  demand  several  changes;  the  layers  next  to  the 
incision  being  untouched  whenever  possible. 

With  all  the  drainage-cases  a  rubber-sheet  must  be 
spread  upon  the  bed  and  soft  pads  laid  over  it  to  catch  the 


102  SURGICAL  THERAPEUTICS 

urine,  these  being  changed  as  often  as  possible.  For  if 
the  patient's  skin  is  not  protected  from  the  irritating  effect 
of  constant  immersion  in  urine,  bed-sores  of  the  most 
aggravated  type  may  form.  To  assist  in  preventing  this 
calamity  the  back,  hips  and  thighs  ought  to  be  bathed  in 
dilute  alcohol  once  every  day;  and  may  be  smeared  with 
vaseline  after  each  alcohol  bath.  As  soon  as  the  strength 
will  permit,  the  patient  must  be  compelled  to  sit  up  in  a 
chair  daily,  upon  a  rubber  ring,  for  as  many  hours  as  pos- 
sible. 

In  perineal  drainage  there  is  likely  to  be  a  considerable 
destruction  of  tissue  by  necrosis — the  urine  getting  into  the 
muscular  and  fascial  layers  in  spite  of  anything  that  can 
be  done.  These  sloughs  must  be  cut  away  from  time  to 
time,  but  not  too  soon;  often  it  is  best  to  wait  several  days 
before  pulling  them  out.  After  granulation  is  well  estab- 
lished there  will  be  no  further  trouble,  but  with  old  people 
the  process  of  granulation  is  not  progressing  satisfactorily 
even  after  two  or  three  weeks,  sometimes,  and  the  con- 
tinuation of  necrosis  becomes  a  serious  menace.  Here 
the  free  application  of  iodoform  may  be  tried,  or  balsam  of 
Peru  smeared  into  the  depths  of  the  wound. 

It  requires  from  two  to  four  weeks  for  the  bladder  to 
close — and  occasionally  there  is  some  leakage  for  many 
weeks. 

Tuberculosis  of  the  Bladder-Wall. — Tuberculosis  of 
the  bladder-wall  is  comparatively  rare,  and  is  usually 
associated  with  tuberculosis  elsewhere.  When  the  only 
or  the  most  conspicuous  lesion,  it  may  be  treated  by 
suprapubic  cystostomy,  cureting  and  packing,  followed 
by  injection  of  iodoform  emulsion.  The  usual  internal 
'treatment  of  tuberculosis  must  be  energetically  pushed. 

Tumors* — Growths  in  the  bladder  may  be  (i)  papil- 
loma,  (2)  carcinoma,  (3)  myoma,  (4)  fibroma,  (5)  sar- 
coma, (6)  gumma,  (7)  cysts.  Nearly  all  are  character- 


BLADDER  103 

ized  by  hematuria.  Diagnosis  is  made  by  cystoscopy. 
Removal  by  earliest  possible  cystotomy  is  the  only  treat- 
ment, save  for  gummatous  tumor,  in  which  potassium 
iodide  may  be  given,  also  mercury. 

Ulcer  of  Bladder. — Ulcers  of  the  bladder  generally 
are  found  close  to  the  urethral  orifice.  They  may  be 
simple  (chronic  and  solitary);  acute  (perforating);  chronic 
tubercular;  syphilitic;  cancerous.  The  three  prominent 
symptoms  are  increased  frequency  of  micturition,  pain 
in  the  penile  portion  of  the  urethra  and  hemorrhage. 
There  are  also  three  stages — usually.  In  the  first  there 
is  usually  some  disturbance  of  micturition;  the  act  is 
more  frequent  and  passage  of  water  is  attended  by  a 
burning  sensation,  particularly  marked  toward  the  end, 
with  more  or  less  discomfort  felt  in  the  penis.  The  urine 
does  not  show  any  very  marked  change,  but  close  exami- 
nation will  show  some  pus,  necrotic  debris  and  exfoliated 
epithelium.  In  the  second  a  cystitis  begins  and  there 
is  an  exaggeration  of  all  the  symptoms.  The  urine  is 
more  purulent  and  contains  more  epithelium  and  debris; 
the  blood,  too,  is  in  larger  amount.  In  the  third,  dis- 
tension of  the  bladder  occurs,  owing  to  lack  of  expulsive 
power;  if  not  relieved  by  cystostomy  the  patient  dies 
of  ascending  infection.  Acute  perforating  ulcer  can 
rarely  be  diagnosticated  antemortem,  save  by  a  skilful 
cystoscopist.  r 

Treatment. — Irrigations  with  silver  nitrate,  from  i  in 
10,000  up  to  i  in  5000  every  second  day,  will  usually 
effect  a  cure  in  the  first  stage.  If  this  does  not  succeed 
the  ulcer  may  be  cauterized  through  a  cystoscope,  or  a 
suprapubic  cystotomy  made  and  the  ulcer  cureted  and 
cauterized  with  the  Paquelin.  In  the  second  stage  curet- 
ing  and  cauterization  with  a  prolonged  drainage  through 
.  a  suprapubic  opening  are  necessary  to  effect  a  cure.  In 
the  third  stage,  drainage,  irrigation  and  gradual  disten- 


104  SURGICAL  THERAPEUTICS 

sion  of  the  bladder  are  all  that  can  be  done,  preferably 
through  a  suprapubic  opening. 

Wounds  of  the  Bladder* — A  direct  blow  may  cause 
rupture  of  a  full  bladder;  a  spicule  of  bone  from  a  frac- 
tured pelvis  may  penetrate  it;  a  stab-wound  of  the  lower 
abdomen  may  enter  it;  and  a  metal  catheter  in  rough 
hands  may  perforate  it.  If  the  peritoneum  has  been 
opened  at  the  same  time  an  immediate  abdominal  section 
is  indicated  to  close  the  hole  in  the  bladder  by  suture  and 
to  clean  out  and  wall  off  the  abdominal  cavity.  But 
when  the  peritoneum  is  not  involved  it  is  best  merely  to 
clean  up  the  wound,  irrigate  the  bladder  thoroughly  through 
a  catheter  in  the  urethra  and  insert  a  drainage-tube  or 
wick  into  the  bladder  through  the  external  wound.  In 
hidden  wounds  like  that  from  catheter  and  bone-fragments, 
suprapubic  cystostomy  and  free  drainage  must  be  made 
without  delay;  extensive  extravasation  of  urine  means  death. 

BLEPHARITIS 

Blepharadenitis. — Inflammation  of  the  Meibomian 
glands  (commonly  called  "stye")  is  best  treated  by  early 
incision  and  evacuation  of  the  pus  and  use  of  warm  anti- 
septic solutions  or  compresses,  a  saturated  solution  of 
boric  acid  being  most  useful.  Styes  signify  eyestrain. 
A  little  mercurial  ointment  promptly  aborts  them. 

Blepharanthracosis. — This  is  a  carbuncular  inflam- 
mation of  the  eyelid.  Treatment  is  the  same  as  for  car- 
buncle (which  see). 

Blepharoedema. — Swelling  or  edema  of  the  eyelids 
may  be  treated  by  compresses  wrung  from  some  astringent 
solution.  Bad  cases  may  require  numerous  small 
punctures,  followed  by  antiseptic  solutions. 

Blepharoadenoma* — A  small  adenoma  growing  on 
the  ciliary  margin  of  the  eyelid.  Excision  as  early  as 
possible  is  the  only  treatment. 


BLOOD:    TRANSFUSION  OF  105 

BLISTERS 

Usually  it  is  best  to  cut  into  the  blisters  and  let  out 
the  serum.  Then  apply  some  soothing  antiseptic  dress- 
ing which  will  exclude  the  air.  A  most  excellent  way  is 
to  saturate  gauze  in  camphophenol  (equal  parts  of  cam- 
phor and  phenol  rubbed  together  in  a  mortar  just  boiled 
or  baked  for  20  minutes;  the  remedy  should  be  kept  in  a 
clean  bottle),  and  cover  the  blister  and  surrounding  sur- 
face with  several  thicknesses,  placing  rubber-tissue  or  oiled 
silk  over  this  and  a  mass  of  absorbent  cotton  over  all, 
holding  the  dressing  in  place  by  a  bandage  or  adhesive 
strips.  This  dressing  need  not  be  disturbed  for  three 
to  five  days. 

BLOOD:    TRANSFUSION  OF 

This  operation  is  again  coming  into  vogue,  and  under 
the  aseptic  technic  lives  are  being  saved  by  it.  When  a 
patient  has  bled  to  unconsciousness,  is  pulseless  and 
cold,  there  may  be  hope  of  restoring  life  if  the  source  of 
hemorrhage  has  been  corrected.  The  radial  artery  of 
the  donator  is  bared  and  opened  and  a  small  glass  or 
aluminum  tube,  sterilized,  introduced  into  it  and  held 
by  a  catgut  ligature  around  its  end;  a  little  blood  being 
allowed  to  flow  (to  determine  that  the  current  has  been 
established)  the  end  of  the  tube  is  closed  and  all  wrapped 
in  a  very  hot,  moist  towel.  The  basilic  vein  of  the  donee 
is  next  exposed  and  opened  as  for  venesection,  the  distal 
end  tied  but  the  proximal  left  open.  The  end  of  the  vein 
being  lifted  out  sufficiently,  blood  is  permitted  to  flow 
from  the  tube  long  enough  to  be  sure  all  air  is  expelled, 
and  then  (with  blood  still  running)  the  end  of  the  tube 
is  slipped  into  the  vein  and  tied  around  with  gut.  Blood 
is  permitted  to  flow  for  about  thirty  minutes  when  the 
vein  and  artery  are  each  closed  by  ligation.  The  dona- 


106  SURGICAL  THERAPEUTICS 

tor's  blood  will  drop  from,  the  normal  5  1-2  or  6  millions 
to  near  4,500,000  in  that  time  (hemoglobin  from  100  to 
about  70),  while  the  donee's  will  rise  correspondingly; 
but  the  former  will  be  restored  to  normal  in  four  or  five 
days,  only  one  day's  detention  from  business  being 
required. 

BOCKHART'S  -BLOOD-SERUM  MERCURY" 

Another  method  of  preparing  mercury  so  it  may  be 
injected  beneath  the  skin  is  that  of  Bockhart: 

Dissolve  3  grams  (45  grains)  of  bichloride  of  mercury 
in  32  grams  (i  ounce)  of  boiling  water;  dissolve  7  grams 
(105  grains)  of  chloride  of  sodium  in  20  grams  (5  drams) 
of  water;  mix  the  mercuric  solution  with  42  grams  (10 
1-2  drams)  of  blood-serum  sterilized  by  Koch's  method 
and  dissolve  the  precipitate  by  adding  the  salt  solution. 
This  makes  a  three-percent  blood-serum  mercury.  Add 
distilled  water  enough  to  make  212  cubic  centimeters 
(6  ounces  and  5  drams),  i.  e.,  double  the  amount  of  fluid, 
so  as  to  reduce  to  a  i. 5-percent  solution,  which  is  practi- 
cally unirritating.  Of  this  15  drops  may  be  injected 
once  daily,  equal  to  gr.  1-4. 

BOILS 

Aborting  Boils. — It  is  possible  to  prevent  suppura- 
tion in  a  small  proportion  of  forming  boils.  As  soon  as 
the  local  inflammation  is  noted  the  following  is  to  be 
applied: 

Fluid  extract  of  ergot 2.0  (dr.    1-2) 

Oxide  of  zinc 8.0  (dis.  2    ) 

Phenol 0.5  (grs.  8     ) 

Lanolin 65.0  (ozs.  2    ) 

This  is  to  be  spread  on  gauze  or  absorbent  cotton  to 
the  size  of  a  silver  dollar,  applied  over  the  boil,  and  held 
by  adhesive  plaster.  It  should  be  replaced  by  belladonna 


BOILS  107 

ointment  in  twelve  hours,  but  may  be  repeated  next  day 
if  the  boil  is  still  red  and  painful. 

Boils  Compared  with  Carbuncles. — The  first  is  a 
staphylococcus,  the  second  a  streptococcus  infection, 
small  boils  sometimes  may  be  aborted  in  their  incipiency 
by  introducing,  with  a  hypodermic  needle  or  sharp  probe, 
a  drop  of  pure  carbolic  acid;  but  this  will  only  aggravate  a 
beginning  carbuncle.  When  a  definite  pus  cavity  has  formed, 
simple  incision,  if  good  gaping  of  the  wound-edges  is  se- 
cured, is  quite  sufficient  for  most  small  boils  and  a  few 
larger  ones.  With  the  larger  kind  free  incision  is  needful, 
and  if  a  small  gauze  drain  is  inserted  there  will  be  a  free 
exit  for  the  discharge;  and  in  a  week,  more  or  less,  good 
granulations  form  and  healing  is  uninterrupted.  Accord- 
ing to  Rand  the  tendency  to  reinoculation  of  adjacent  hair 
follicles  can  be  prevented  and  the  comfort  of  the  patient 
promoted  by  washing  the  skin  with  alcohol  and  applying 
hot  antiseptic  compresses  of  boric  acid  or  weak  bichloride 
solutions.  Large  boils  can  be  emptied  more  completely, 
and  better  drainage  is  secured,  if  a  small  oval  piece  of 
skin  is  excised. 

The  best  treatment  for  carbuncles  is  to  thoroughly 
excise  all  of  the  inflamed  tissue,  burn  with  pure  carbolic 
acid,  neutralize  with  pure  alcohol  and  then  pack  with 
gauze,  this  being  done  under  anesthesia.  Unfortunately, 
many  patients  will  not  submit  to  such  heroic  treatment 
until  the  disease  is  far  advanced;  but  if  the  carbuncle  is 
small,  excision  under  cocaine  and  ethyl-chloride  anesthesia, 
combined,  may  be  possible.  Usually,  however,  all  the 
patient  will  permit  is  incision  of  the  central  part  of  the 
mass  of  infiltrated  tissue,  with  multiple  incisions  in  the 
large  carbuncles.  Then  the  application  of  hot  antiseptic 
compresses  will  soften  the  tissues  and  encourage  the  sepa- 
ration of  sloughs.  With  the  aged  vigorous  supportive 
treatment  is  imperative. 


108  SURGICAL  THERAPEUTICS 

Prevention  of  Boils.  —  Whenever  the  patient  is 
seen  early  enough,  it  is  always  proper  to  attempt  to  abort 
a  boil,  since  such  treatment  does  not  aggravate  the  con- 
dition if  the  effort  fails,  and  much  suffering  is  avoided 
if  the  attempt  proves  successful.  The  boil  should  be 
well  covered  with  a  tampon  of  cotton  which  is  kept 
saturated  with  the  following  solution: 

Chloral 10.0  (2  1-2  drs.) 

Glycerin 20.0  (5  drs.) 

Water 20.0  (5  drs.) 

Certain  observers,  working  along  the  theory  of  the  des- 
truction of  the  staphylococcus,  bathe  small  boils  frequently 
with  a  lotion  of  salicylic  acid  in  alcohol,  2-percent;  or 
a  5o-percent  plaster  of  the  same,  changed  four  or  five 
times  a  day  to  hasten  the  necrosis  in  large  boils.  In 
furunculosis  involving  an  area  of  considerable  size,  a 
2  1-2  percent  ointment  of  salicylic  acid  in  vaselin  may  be 
applied  once  a  day,  after  gentle  washing  with  soap  and 
warm  water.  Either  ordinary  lime  water  on  compresses 
covered  with  oiled  paper  or  silk,  or  a  solution  of  calcium 
chloride  applied  in  the  same  manner,  will  promote  sup- 
puration more  quickly  than  the  ordinary  poultice.  A 
25-percent  solution  of  ichthyol,  applied  every  two  hours, 
will  diminish  the  area  involved  in  inflammation,  and 
consequently  lessen  the  pain  and  shorten  the  duration; 
while  certain  experimenters  also  assert  abortive  power 
for  the  same  application.  A  saturated  solution  of  com- 
mon baking  soda  applied  on  a  compress  will  relieve  the 
pain  of  a  boil  at  any  stage.  If  applied  in  the  very  incip- 
iency,  20  grains  of  silver  nitrate  in  an  ounce  of  spirit  of  ni- 
trous ether,  painted  frequently  over  the  inflamed  surface,, 
will  abort  many  forming  boils.  Calcium  sulphide  should 
always  be  given  internally  and  pushed  till  all  the  secretions 
smell  of  hydrogen  sulphide, 


BOILS  109 

Boils  may  sometimes  be  aborted  by  first  energetically 
rubbing  the  furuncle  with  the  tincture  of  green  soap; 
then  washing  it  with  alcohol  (40-  to  5o-percent);  then  apply- 
ing a  thin  compress  of  absorbent  cotton  moistened  with 
alcohol,  which  is  kept  in  place  until  the  alcohol  has  all 
evaporated,  then  making  another  application  of  the  green 
soap,  but  allowing  the  lather  to  dry  on  the  spot,  which 
is  then  left  uncovered.  Sometimes  it  is  necessary  to 
repeat  this  maneuver  after  several  hours.  In  order  to 
be  successful  the  treatment  should  be  applied  early.  As 
soon  as  it  is  apparent  that  suppuration  is  inevitable,  free 
incision  is  to  be  made  and  the  surrounding  hair-follicles 
protected  from  infection  by  careful  attention  to  post- 
operative cleanliness. 

Treatment  of  Boils. — While  a  single  boil  is  but  a  lo- 
cal abscess  around  the  root  of  a  hair,  by  infection  of  other 
follicles  many  other  boils  may  arise.  This  is  more  probable 
when  there  is  a  general  impoverishment  of  the  system 
and  want  of  proper  elimination.  Certain  trades,  too, 
predispose  to  boils,  as  workers  in  oil  or  paraffin,  and  coal- 
shovelers.  The  proper  treatment,  then,  is  net  only  early 
incision  and  proper  drainage  of  every  suppurative  point, 
but  extreme  cleanliness  of  the  skin  around  the  abscess, 
changing  of  dressings  often  enough  to  prevent  the  pus 
running  over  healthy  skin.  Internally  a  teaspoonful  of 
effervescent  magnesium  sulphate  four  times  a  day  does 
good,  as  also  do  tonics  like  iron,  arsenic  and  strychnine, 
as  in  the  "triple  arsenates".  Calcium  sulphide,  given 
to  saturation,  is  highly  recommended  and  really 
very  valuable,  and  nuclein  is  useful.  To  hasten  sup- 
puration (when  it  seems  inevitable)  poultices  are  cf 
undoubted  value;  and  a  little  extract  of  opium  may  be 
added  to  allay  pain.  But  after  the  boil  has  been  widely 
opened  the  poultices  should  not  be  continued — a  simple 
antiseptic  gauze  dressing  being  all  that  is  required.  Fre- 


110  SURGICAL  THERAPEUTICS 

quent  dressings  should  be  made  to  prevent  the  pus  con- 
taminating contiguous  surfaces.  Patients  suffering  from 
little  boils  should  be  instructed  not  to  scratch  or  rub  the 
skin  near  the  boil,  otherwise  pus  will  be  gotten  under  the 
finger-nails  and  other  boils  produced  by  transference  of 
poison;  hence  at  night  the  affected  part  should  be  covered 
to  prevent  scratching  during  sleep. 

BONE:    DISEASES  OF 

The  principal  affections  of  bones  are:  (i)  Inflamma- 
tion of  bone  (see  "Osteitis");  (2)  inflammation  of  medulla 
(see  "Osteomyelitis");  (3)  inflammation  of  bony  covering 
(see  "Periostitis");  (4)  necrosis  of  bone  (see  "Caries");  (5) 
osteomalacia  (which  see);  (6)  rachitis  (see  "Rickets");  (7) 
syphilis;  (8)  tuberculosis;  (9)  tumors. 

Bones  may  also  become  atrophied  (in  old  age  and  in 
certain  injuries)  as  well  as  hypertrophied,  but  there  is  no 
treatment  for  either.  Syphilis  will  be  mentioned  under 
"Caries",  and  tuberculosis  will  be  discussed  under  Diseases 
of  the  Joints.  Tumors  found  in  bone  are  usually  (a)  en- 
chondromata,  (b)  exostoses,  (c)  myeloid,  (d)  sarcomata, 
(e)  carcinomata,  and  (f)  cysts.  All  should  be  removed 
as  soon  as  found. 

BOW-LEGS 

If  the  deformity  be  due  to  mere  curvature  of  the  bones 
it  may  readily  be  corrected  by  simply  bandaging  tightly 
to  a  straight  splint  on  the  inner  aspect  of  the  leg,  tightening 
the  bandage  from  time  to  time  during  the  first  two  years 
of  life.  But  usually  the  defect  is  in  the  knee-joint;  when 
an  appropriate  apparatus  must  be  made  and  fitted  to  the 
legs  as  the  child  begins  to  walk,  the  straps  being  tightened 
once  in  two  weeks  and  the  length  of  the  brace  increased 
as  the  child  grows.  Cases  seen  after  the  bones  have 
hardened  (beyond  the  5th  to  8th  year)  can  be  benefited 
only  by  operative  treatment. 


BREAST:     DISEASES  OF  111 

BREAST:    DISEASES  OF 

Breasts:  Inflammation  of. — Mastitis  may  yield  to 
the  local  use  of  oleate  of  mercury  if  it  be  properly  applied 
before  suppuration  arises.  To  the  oleatum  hydrargyri  add 
a  little  morphine  (the  basic  alkaloid  morphina — not  the 
sulphate,  hydrochloride,  etc.,  which  are  not  soluble  in  oleic 
acid);  a  little  of  the  mixture  is  to  be  lightly  rubbed  over 
the  affected  area.  The  rubbing  must  be  very  gentle  or 
severe  irritation  of  the  skin  will  follow;  indeed,  with  a  very 
delicate,  tender  skin  it  may  be  better  to  apply  the  ointment 
with  a  brush.  Twice  a  day  is  as  often  as  most  skins  will 
stand. 

Imperfect  Operations  for  Cancer. — In  removing 
carcinoma  of  the  breast  there  are  two  chief  reasons  for  re- 
turn of  the  disease:  (i)  Want  of  care  in  dissecting  out  all 
the  fat  and  glands  of  the  axilla,  and  (2)  leaving  too  much  of 
the  skin  over  the  affected  area.  Of  the  first  it  may  be  said 
that  a  large  majority  of  operators  spend  too  little  time  in 
removing  the  axillary  contents — it  requires  from  a  half- 
hour  to  an  hour  to  get  all  the  tissues  out  which  may  pos- 
sibly be  implicated  by  the  cancerous  process.  Not  only 
the  fat  and  glands  of  the  axilla  should  be  excised — the 
chain  of  lymphatics  running  down  beside  the  long  thoracic 
vessels,  those  running  down  behind  the  scapula  and  those 
extending  up  beneath  the  clavicle  should  be  removed; 
indeed,  some  surgeons  now  advocate  removal  of  the  cervical 
glands,  but  this  is  scarcely  needful,  unless  they  can  be  felt 
beneath  the  skin  and  muscle;  and  then  it  is  doubtful  if  any 
operation  at  all  is  justifiable.  Of  the  second  it  may  be  said: 
It  is  well  to  cut  wide  of  the  affected  area,  running  the  risk 
of  having  to  make  a  Thiersch  graft  rather  than  to  leave 
skin  which  may  be  the  site  of  incision-recurrence — which 
is,  I  regret  to  say,  a  very  frequent  thing  in  the  work  of  in- 
experienced operators. 


112  SURGICAL  THERAPEUTICS 

BRIGHT'S  DISEASE:    OPERATION  FOR 

Extensive  experimental  work  in  decapsulation  of  the 
kidney  has  proven  that:  (i)  Chronic  nephritis  should  not 
be  operated  on  until  medical  treatment  has  proven  of 
no  avail.  (2)  The  time  for  operation  is  when  it  is  noticed 
that  the  process  is  advancing  rapidly  and  it  is  feared  that 
the  heart  will  soon  become  overtaxed.  (3)  The  operation 
for  chronic  Bright's  disease  which  has  proven  least  danger- 
ous, and  which  has  shown  the  best  results,  is  nephropexy, 
performed  on  a  single  kidney.  (4)  The  most  unfavorable 
cases  for  operation  are  those  of  diffuse  nephritis.  (5) 
Cases  of  general  anasarca  with  bad  heart-action  should 
not  be  operated  on;  if  the  heart -action  is  good,  an  operation 
performed  as  a  dernier  ressort  may  give  the  patients  a  few 
extra  months  of  life,  provided  they  survive  it.  (6)  Where 
there  has  been  a  marked  destructive  process  in  the  kid- 
neys, as  a  result  of  nephritis,  the  operation  may  relieve 
for  a  number  of  weeks  or  months,  but  patients  generally 
fail  again  and  die  when  the  new  capsule  begins  to  contract. 

The  operation,  since  it  is  as  yet  purely  experimental, 
should  be  done  by  none  but  a  surgeon  of  great  repute, 
since  a  fatal  termination  in  the  hands  of  a  surgeon  with 
only  a  local  reputation  might  unnecessarily  entail  great 
loss  of  prestige. 

BUBO 

Bubonocele. — This  is  an  inguinal  hernia  in  which 
the  gut  or  omentum  does  not  extend  beyond  the  inguinal 
canal.  The  treatment  is  the  same  as  any  other  inguinal 
hernia  (which  see).  *  To  the  inexperienced  surgeon  it  is  of 
chief  interest  on  account  of  the  liability  to  mistake  it  for  a 
bubo,  particularly  when  clap  or  chancroid  is  found. 

Phenol  for  Buboes — When  buboes  are  seen  very 
early,  before  any  great  amount  of  redness  of  skin  is  present, 
the  skin  may  be  frozen  with  chloride  of  ethyl  and  ten  drops 


BUBO  113 

of  a  solution  of  phenol  injected  into  the  middle  of  each  en- 
larged gland;  the  solution  being  of  this  strength: 

Phenol  0.5  (grs.  8) 

Distilled  water 32.0  (oz.    i) 

The  skin  should  be  carefully  scrubbed  and  washed  with 
ether  or  alcohol  before  the  needle  is  introduced,  and  the 
needle  itself  should  lie  in  alcohol  five  minutes  before 
using  and  then  be  passed  through  an  alcohol  flame  on  its 
way  to  the  gland;  and  the  fingers  should  then  not  touch 
the  needle  until  the  injection  is  made,  otherwise  a  staphylo- 
coccus  infection  may  result  with  extensive  suppuration. 

Treatment  of  Buboes. — If  there  be  much  inflamma- 
tion, as  evidenced  by  pain,  tenderness  and  especially  red- 
ness, the  swelling  and  suppuration  can  be  prevented  in 
some  cases  by  putting  the  patient  in  bed  and  applying  an 
ice-bag  to  the  affected  surface.  If  the  patient  cannot  stay 
in  bed  the  bubo  may  be  painted  with  several  layers  of 
collodion  and  a  compress  applied  tightly  by  means  of  a 
spica  bandage.  As  soon  as  fluctuation  is  detected,  cocaine 
should  be  injected,  the  abscess  opened  freely  and  all  the 
infected  gland  removed  by  cureting.  The  wound  is  then 
packed  with  gauze,  which  is  removed  in  twenty-four  hours 
and  the  pocket  filled  with  some  dusting  powder,  preferably 
equal  parts  of  calomel  and  subiodide  of  bismuth,  and  an 
antiseptic  gauze  dressing  applied.  The  less  frequently  the 
dressings  are  changed,  compatible  with  cleanliness,  the 
sooner  will  the  wound  heal,  i.  e.,  after  granulations  have 
begun  to  form.  Calcium  sulphide  may  be  given  internally. 

Treatment  of  Sympathetic  Bubo. — The  name  of 
sympathetic  bubo  is  applied  to  a  bubo  resulting  from 
irritation,  friction  or  injury  and  not  from  venereal  disease. 
It  is  to  be  treated  as  any  other  lymphadenitis  -(which  see). 

Welander's  Treatment. — This  is  removal  of  pus  (if 
present)  by  aspiration,  irrigation  with  i  in  1000  bichloride 
solution,  and  injection  of  benzoate  of  mercury  solution, 


114  SURGICAL  THERAPEUTICS 

with  closure  by  collodion.  It  is  best  employed  before  sup- 
puration begins,  the  mercuric  benzoate  being  injected  with- 
out aspiration  and  irrigation. 

BURNS 

Phenol  for  Barns* — If  phenol  (carbolic  acid)  is  to 
be  used  for  burns — and  it  is  one  of  the  most  satisfactory 
of  all  applications — it  must  be  in  full  strength.  It  causes 
pain  for  an  instant,  followed  immediately  by  a  soothing 
sensation  of  coolness,  because  if  put  on  in  9  5 -percent  solu- 
tion (phenol  liquefactum)  it  coagulates  the  albumin  on  the 
surface  of  the  burn,  excluding  the  air  temporarily  and  at 
the  same  time  acting  as  an  analgesic  to  the  injured  nerve- 
filaments.  Before  applying  it  all  blisters  should  be  pricked 
and  tags  of  burned  tissue  cut  away.  Gauze  saturated  in 
carbolized  oil  (sterilized)  should  be  put  on  the  burn,  many 
.thicknesses,  with  cotton  and  loose  bandage  over  all.  Mor- 
phine and  strychnine  ought  to  be  given  at  once  hypo- 
dermically. 

An  ointment  of  one  part  boric  acid  to  eight  of  vaseline 
is  excellent  to  saturate  gauze  in,  to  apply  next  to  the  burn 
after  removal  of  the  first  dressing.  Or  one  may  employ 
the  camphophenol  liquid  made  of  equal  parts  of  camphor 
and  pure  phenol. 

In  making  the  dressings,  if  the  burned  area  is  large, 
only  a  small  part  should  be  uncovered  at  one  time  to 
prevent  chilling.  The  dressings  should  not  be  changed 
oftener  than  two  or  three  days  unless  the  discharge  is  so 
great  as  to  compel  it,  or  the  odor  is  very  annoying. 

When  granulations  are  progressing  well  healing  may 
often  be  accelerated  by  skin-grafting,  when  the  burn  is 
extensive. 

Severe  Burns. — Shock  is  sometimes  profound  in  severe 
burns,  amounting  to  total  collapse  in  some  instances.  As 
this  is  dependent  in  great  part  on  the  intensity  of  pain  a 


BURSITIS  115 

good  plan  is  to  give  at  once  as  large  a  dose  of  morphine 
as  the  patient  will  stand  (children  cannot  tolerate  much 
morphine),  usually  to  an  adult  1-2  grain  hypodermically 
with  1-30  grain  of  strychnine;  or  better  still,  a  tablet  of  the 
hyoscine-morphine-cactin  anesthetic,  and  a  second  one  in 
two  hours  if  needed.  Blankets  should  be  wrapped  around 
the  body,  and  the  patient  speedily  removed  to  a  hospital 
or  his  home,  where  artificial  heat  may  be  applied  if  the 
shock  continues.  Here  the  popular  remedy,  a  "good 
drink  of  whisky,"  is  indicated,  and  it  may  be  repeated  in 
a  half  hour  if  collapse  continues.  Digitalin  may  also  be 
injected  a  half  hour  after  the  morphine,  with  glonoin  fol- 
lowed by  atropine  or  hyoscyamine  if  there  is  shock, 
shown  by  pallor  and  coldness  of  the  skin.  Indeed  glonoin, 
atropine  and  strychnine  are  generally  indicated  in  shock. 
A  most  popular  application,  used  in  nearly  all  great 
iron-foundries,  is  "carron  oil"  of  this  composition: 

Lime  water   1 25 .o 

Linseed  oil —  -i2S-o 

Phenol   10.0 

Gauze  is  saturated  with  this  and  applied  to  the  burned 
surfaces;  and  changed  every  twelve  hours.  In  small  burns 
a  saturated  solution  of  carbonate  of  sodium  (common 
washing  soda)  checks  the  pain.  The  best  application  is 
5-percent  aqueous  solution  of  picric  acid,  clothes  or  gauze 
being  wrung  out  of  it  and  applied  to  all  the  affected  sur- 
faces; but  it  stains  everything  a  bright  yellow  which  will 
not  come  off.  Rubber  gloves  must  therefore  be  used  in 
handling  it.  • 

BURSITIS 

Inflammation  of  the  bursa  is  not  common.  When  it 
does  occur  it  may  be  of  tuberculous  variety  '(a,  socalled 
"inflammation")  or  it  may  be  due  ^>  infection  with  some 


116  SURGICAL  THERAPEUTICS 

of  the  more  active  pyogenic  organisms  (staphylococci  and 
streptococci). 

Acute,  suppurative  bursitis  is  usually  caused  by  a  severe 
bruise  or  a  penetrating  wound,  and  if  not  properly  treated 
will  extend  in  a  most  remarkable  manner,  involving  con- 
tiguous tendons,  ligaments,  joints  and  even  bones.  Some- 
times by  reason  of  injury  to  blood-vessels  there  is  an  accu- 
mulation of  blood  in  the  bursa  or  a  mere  distension  with 
serum,  the  membrane  itself  being  thickened  but  not  pus- 
infected.  In  case  of  doubt  it  is  therefore  best  to  aspirate 
before  making  free  incision;  if  it  be  serum  or  blood,  removal 
through  an  aspirator  followed  by  long-continued  immobil- 
ization will  effect  a  cure;  but  if  the  fluid  be  pus  free,  incision 
and  drainage  is  the  only  rational  treatment,  "the  earlier 
the  better  for  the  integrity  of  the  neighboring  joint. 

There  is  a  peculiar  affection,  described  by  older  writers 
as  "chronic  bursitis,"  though,  in  many  instances,  it  un- 
doubtedly is  not  a  true  inflammation.  It  is  characterized 
by  thickening  of  the  wall  by  repeated  deposits  of  organized 
lymph  until  the  whole  bursal  cavity  is  finally  filled  by  a 
tumor  of  almost  cartilaginous  consistency.  The  only 
treatment  is  excision  under  strictest  asepsis. 

The  tuberculous  trouble  does  not  differ  materially  in 
either  character  or  treatment  from  fungous  synovitis  (which 
see). 

CANCER 

This  is  a  general  term  expressive  both  of  carcinoma 
and  sarcoma — any  malignant  growth  is  "cancer. "  Certain 
forms  have  distinctive  names,  as  alveolar  cancer,  a  carci- 
noma with  an  alveolar  structure;  colloid  cancer,  one  con- 
taining colloid  material;  cancer  en  cuirasse,  a  disseminated, 
lenticular  carcinoma  of  the  skin  encircling  the  chest;  epithe- 
lial cancer,  a  carcinoma  of  the  epithelial  structure,  espe- 
cially of  lip  and  cervix  Creallv  all  carcinomata  are  epithelial 


CANCER  117 

cancers);  melanotic  cancer,  one    containing  pigment  and 
generally  regarded  as  unusually  malignant. 

Cancer  "Cares/* — About  twenty  percent  of  perma- 
nent cures  follow  radical  operation  as  at  present  practised. 
This  percentage  might  easily  be  doubled  by  early  recog- 
nition and  immediate  extirpation.  Too  many  doctors 
delay  in  the  hope  that  they  have  made  a  mistake  in  diag- 
nosis; using  palliative  or  delusive  curative  measures.  If 
they  would  but  remove  the  growth  first  and  use  the  "reme- 
dies" afterward,  many  more  lives  might  be  saved.  Tryp- 
sin  has  recently  attracted  much  attention;  but  while  it  is 
true  that  cancer-cells  are  easily  dissolved  by  trypsin  and 
some  patients  have  improved  greatly  under  its  hypodermic 
use,  no  absolute  cure  has  yet  been  reported,  and  the  ques- 
tion of  its  beneficial  action  is  still  sub  judice.  Radium, 
too,  is  still  under  trial — with  probabilities  all  against  its 
general  usefulness.  The  Finsen  light  has  proven  of  value 
only  in  superficial  growths  which  are  far  better  burned  out 
with  the  Paquelin  cautery.  As  for  the  x-ray,  its  curative 
influence  has  been  greatly  overestimated  except  in  skin- 
cancer  and  lupus;  in  truth,  it  may  now  be  positively  said 
that  for  extensive  carcinoma  the  Roentgen-ray  exercises 
no  actual  curative  effect,  its  advantage  being  only  in  the 
fact  that  it  exerts  a  beneficial  analgesic  effect,  and  in  ulcera- 
ting tumors  also  causes  a  diminution  of  the  offensive  dis- 
charge; in  many  cases  there  is  a  temporary  recedence  of 
the  nodules,  but  never  a  lasting  effect.  All  of  these,  then, 
should  be  reserved  for  use  after  excision  of  the  malignant 
growth.  The  latest  addition  to  possible  curative  agents 
is  a  serum  taken  from  sheep  inoculated  with  cancer;  but 
until  the  cause  of  carcinoma  can  be  determined  and  iso- 
lated, little  is  to  be  hoped  from  the  use  of  sera.  When 
extirpation  is  impossible  on  account  of  location  or  extent 
of  the  tumor,  palliative  operations  are  justifiable;  ligation 
of  the  carotid  in  huge  cancer  of  the  neck  may  arrest  its 


118  SURGICAL  THERAPEUTICS 

growth  for  months;  gastroenterostomy  for  cancer  of  the 
pylorus  often  prolongs  the  life  of  the  patient  for  many 
years;  vaginal  hysterectomy  may  give  great  comfort  and 
add  years  to  the  life  of  a  doomed  woman;  and  so  on  through 
the  list.  Just  because  a  diagnosis  of  cancer  has  been 
verified  a  doctor  should  not  abandon  the  victim  to  his 
fate — much  may  be  done  to  encourage,  to  alleviate,  and 
to  prolong  life. 

Condurango  in  Cancer  of  the  Stomach, — In  inoper- 
able cancer  of  the  stomach  condurangin,  the  glucoside 
which  is  the  active  principle  of  condurango,  is  worthy  of 
trial,  great  improvement  having  been  recorded  under  its 
influence.  It  may  be  obtained  in  the  form  of  a  granule 
containing  one  milligram  (gr.  1-67).  One  may  be  given 
from  three  to  six  times  a  day  when  there  is  the  least  food 
in  the  stomach;  best  dissolved  in  a  little  water  just  before 
taking.  Small  doses  of  sulphate  of  codeine  should  be 
given  at  the  same  time  if  there  be  much  pain.  But  it 
should  be  remembered  that  the  presence  of  a  pyloric 
tumor  is  no  longer  regarded  as  prohibiting  operative  treat- 
ment: a  palliative  gastroenterostomy  at  least  often  may 
be  performed  with  great  benefit. 

Cure  of  Mediastinal  Carcinoma. — Pfahler,  of  Phila- 
delphia, has  reported  six  cases  in  which  carcinoma  of 
the  mediastinum  developed  after  cancer  of  the  breast. 
All  of  the  patients  had  been  operated  on  previously. 
They  were  treated  by  x-ray  and  three  have  apparently 
recovered. 

For  Inoperable  Cancer. — A  very  good  local  appli- 
cation to  cancer  (especially  of  the  breast)  is  an  ointment 
containing  morphine  and  atropine;  and  better  for  its 
soothing  effect  is  the  old-fashioned  conium  poultice. 
This  may  be  made  from  the  fresh  leaves,  or  one-half 
ounce  of  the  succus  conii  may  be  added  to  an  ordinary 
bread  poultice. 


CANCER  119 

Marsden's  Paste  for  Cancer,, — The  celebrated 
"Marsden's  paste"  used  by  most  "cancer  doctors"  con- 
sists of 

Arsenous  acid i  ounce 

Powdered  acacia i  ounce 

Water    '. 5  drams 

Some  of  this  arsenical  mucilage  is  smeared  over  the  malig- 
nant growth  morning  and  evening,  care  being  taken  not 
to  cover  healthy  skin.  Separation  of  sloughs  is  encour- 
aged by  poulticing,  which  also  gives  temporary  respite 
from  suffering,  because  the  arsenic  causes  intense  destruc- 
tive inflammation.  Absorption  is  not  possible  if  plenty 
be  applied;  a  small  quantity  on  a  raw  surface  might  lead 
to  arsenical  poisoning,  but  a  large  amount  produces  such 
severe  inflammation  that  perfect  safety  is  assured,  since 
inflamed  tissues  lose  the  power  of  absorption.  But 
the  treatment  is  very  painful  and  tedious  and  so  has  fallen 
into  well-deserved  disuse  by  the  regular  profession.  One 
can  do  in  five  minutes  with  the  Paquelin  cautery  without 
pain  (under  cocaine)  what  the  cancer  quacks  require 
weeks  of  terrible  suffering  to  accomplish. 

Methylene-Bltte  for  Cancer. — After  the  excite- 
ment over  reported  cures  of  cancer  by  use  of  pyoktanin 
subsided,  a  few  careful  investigators  continued  their 
experimental  treatment  upon  inoperable  carcinoma.  It 
has  been  conclusively  demonstrated  that  the  internal 
use  of  methylene  hydrochloride  in  pill  form  is  followed 
by  remarkably  good  effects.  The  dose  at  the  beginning 
is  2  grains  daily,  to  be  gradually  increased  to  3,  4  and  6 
grains.  To  relieve  the  strangury  sometimes  produced, 
it  is  necessary  to  combine  with  the  pills  3-4  grain  of  extract 
of  belladonna  distributed  over  the  twenty-four  hours. 
Arsenous  acid,  strychnine,  or  a  cathartic  may,  if  neces- 
sary, be  incorporated  in  the  prescription.  The  patient 
must  be  warned  that  the  urine  will  turn  blue  and  will 


120  SURGICAL  THERAPEUTICS 

permanently  stain  clothing.  In  some  instances  the 
patients  gain  remarkably  in  weight  and  strength  and 
the  tumor-mass  may  be  decidedly  reduced  in  size.  Life 
has,  apparently,  been  prolonged  from  two  to  eight  years, 
but  no  patient  has  been  cured. 

Prevention  of  Cancer, — While  we  have  not  yet 
learned  the  remote  cause  of  cancer,  certain  things  have 
been  demonstrated  as  the  direct  cause;  an  avoidance  of 
these  may  prevent  the  appearance  of  the  malady  in  those 
predisposed  to  its  development,  as  well  as  ward  off  a 
return  in  those  patients  who  have  been  subjected  to  opera- 
tion. The  directions  given  by  Keetley  are:  (i)  Steril- 
ize all  food.  A  large  proportion  of  cancers  attacks  the 
alimentary  canal,  and  especially  the  parts  where  food 
and  feces  tarry.  (2)  Insist  upon  sufficient  and  regular 
toilet  and  protection  of  the  nipples  and  of  the  genitalia. 
It  is  significant  that  these  organs  are  especially  often 
polluted  by  stale  secretions  and  discharges,  and  are  more 
frequently  handled  by  their  owners  than  any  other  part 
of  the  person  usually  covered  by  clothing.  (3)  Order 
due  care  of  the  mcruth  and  teeth.  (4)  The  dressings  of 
discharging  malignant  sores  and  tumors  should  be  burned, 
and  patients  and  attendants  must  be  instructed  especially 
not  to  pollute  either  the  fingers  or  the  underlinen.  (5) 
Non-malignant  sores  and  tumors  should  be  cured,  and 
especially  not  allowed  to  drift  on  if  chronic.  (6)  Can- 
cerous and  doubtful  tumors  and  ulcers  should  be  excised 
promptly.  (7)  Abstinence  should  be  practised  from 
alcohol,  tobacco,  and  from  foods  which  leave  waste  prod- 
ucts, of  which  the  kidneys,  the  bowels,  and  the  skin  can 
not  easily  and  thoroughly  get  rid,  and  which  thereby 
provoke  and  sustain  the  chronic  inflammations  and  ulcers 
which  so  often  pave  the  way  for  cancer.  (8)  Physical 
familiarity  should  be  avoided,  except  with  those  who  are 
nearest  and  dearest  to  us.  (9)  Much  thought  should  be 


CANCER  121 

given,  especially  by  mistresses  and  housekeepers,  to  the 
service  as  well  as  to  the  cooking  of  food,  with  a  view  to 
disease-prevention.  Special  attention  should  be  paid  to 
the  sterilization  of  milk  and  its  products:  cheese  and 
butter. 

Radium  Treatment  of  Cancer. — McFarlane's  inves- 
tigation shows  that  of  the  many  thousands  of  cases  of 
cancer  subjected  to  the  radium-treatment  13  rodent  ulcers 
were  reported  cured,  14  epidermoid  cancers  cured,  i 
malignant  wart  cured,  n  cases  of  cancer  of  the  esophagus 
slightly  improved,  27  carcinomas  unaffected,  i  malignant 
wart  unaffected,  i  malignant  mole  unaffected,  i  rodent 
ulcer  unaffected.  The  advantages  of  radium  are  its 
portability,  and  the  ease  with  which  it  can  be  applied 
and  accurately  localized."  From  the  foregoing  summary 
we  may  conclude  that  it  has  a  distinct,  though  altogether  very 
limited,  field  of  usefulness  in  the  treatment  of  malignant 
disease.  Its  action  is  similar  to  that  of  the  Roentgen  ray, 
but  much  weaker.  It  is  preferable  to  the  Roentgen  ray 
in  the  treatment  of  small  rodent  ulcers,  and  is  available 
for  use  in  inaccessible  cavities. 

Trypsin  in  Cancer. — Results  from  the  use  of  trypsin 
in  cancer  are  not  yet  definite.  The  best  report  yet  pub- 
lished is  that  of  Morton  who  instituted  a  series  of  experi- 
ments consisting  of  the  consecutive  use  of  trypsin  in  a 
group  of  about  30  cases  of  cancer,  both  hospital  and  pri- 
vate. Two  of  these,  patients  with  facial  cancer,  are 
cured  to  date.  In  one  case,  a  remarkable  process  of 
retrogression  by  degeneration  and  atrophy  of  a  carcinoma- 
tous  breast-gland  to  final  and  curative  obliteration,  has 
been  demonstrated  microscopically.  In  all  cases  signs 
of  amelioration  in  the  progress  of  the  disease  have  been 
observed.  It  has  been  demonstrated  that  both  local 
and  constitutional  reaction  may  be  produced  by  the  use 
of  trypsin.  Enlarged  glands  have  rapidly  diminished  in 


122  SURGICAL  THERAPEUTICS 

size.  Trypsin  has  a  decided  effect,  Morton  declares,  in 
reducing  cancer  cachexia,  and  in  improving  the  general 
health.  Even  in  severe  cases  of  uterine  cancer  involving 
the  associated  pelvic  organs  the  disease  may  be  brought 
to  a  halt.  The  influence  of  amylopsin  seems  to  have  had 
much  to  do  with  favorable  results. 

CANCRUM  ORIS 

This  disease,  frequently  called  "noma,"  has  been 
described  as  a  gangrenous  stomatitis,  or  gangrenous 
ulceration  of  the  mouth,  though  it  is  not  a  true  gangrene. 
It  is  a  disease  of  early  life,  attacking  children  between 
the  ages  of  one  and  five  years,  and  consists  of  foul,  deep 
ulcers  of  the  mucous  surface  of  the  cheeks  or  lips.  While 
there  is  no  pain,  general  weakness  is  pronounced  and 
unless  the  disease  is  quickly  checked  the  child  dies  from 
exhaustion  or  from  septic  fever.  Under  perfect  anesthesia 
the  ulcer  must  be  burned  with  the  Paquelin  cautery  to 
the  uttermost  recess,  and  then  dressed  as  a  simple  burn. 
As  the  disease  is  due  to  general  debility,  good  food  and 
tonics  are  radically  indicated.  Alcoholic  drinks  (wine) 
and  strychnine  with  triple  arsenates  do  good  if  accom- 
panied by  proper  food.  The  wound,  though  large,  will 
heal  by  granulation  if  kept  covered  by  antiseptic  dress- 
ings, but  changed  often  on  account  of  wetting  by  saliva. 
Any  tendency  to  spread  at  some  particular  point  must  be 
combatted  by  instant,  and  free,  use  of  cautery. 

CANKER 

Canker  is  a  name  used  by  the  laity  to  mean  an  ulcer 
in  the  mouth:  ulcerative  stomatitis.  If  the  ulcer  be 
burned  twice  or  three  times  in  a  week  with  pure  nitrate 
of  silver  and  a  mouth-wash  of  saturated  solution  of  potas- 
sium chlorate  given,  the  "canker"  will  readily  heal  in  a 
few  days. 


CARBUNCLE  123 

CARBUNCLE 

From  a  streptococcal  infection  in  the  deeper  layers 
of  the  skin  there  is  formed  a  hard,  circumscribed,  pain- 
ful inflammation  of  the  subcutaneous  cellular  tissue, 
with  tendency  to  form  several  openings  through  the  skin. 
It  is  much  more  serious  than  a  boil  (a  simple  staphylo- 
coccus  infection)  and  is  accompanied  by  chill,  fever  and 
decided  constitutional  -symptoms,  chief  of  which  is  pro- 
found weakness;  indeed  under  old  lines  of  treatment  it 
was  presumed  that  a  carbuncle  in  an  old  person  meant 
death.  It  certainly  does  not  if  he  will  submit  to  radical 
operation:  excision  of  all  implicated  tissue  under  com- 
plete anesthesia,  the  knife  not  being  allowed  to  touch 
infected  tissue;  if  this  is  not  permitted  the  next-best  thing 
is  to  eradicate  it  thoroughly  by  burning  with  the  Paquelin 
cautery  under  cocaine  anesthesia.  If  neither  can  be 
done,  the  mass  should  be  split  deeply  from  side  to  side, 
with  a  cross-cut  from  top  to  bottom,  and  kept  covered 
with  ichthyol  and  belladonna  ointment  until  the  infected 
mass  (popularly  called  "the  core")  drops  out,  when  it 
may  be  treated  as  a  simple  sore.  Stimulants  and  two- 
decigram  (three-grain)  doses  of  quinine  four  times  a  day 
with  two  milligrams  (1-30  grain)  of  strychnine  sulphate 
should  be  ordered,  together  with  a  mos.t  nourishing  diet. 

Belladonna  for  Carbuncles. — A  most  soothing,  agree- 
able application  for  a  forming  carbuncle  is  equal  parts  of 
extract  of  belladonna  and  ichthyol  smeared  on  cloth 
and  applied  to  the  inflamed  area  and  an  inch  or  more 
of  adjacent  skin.  If  used  early,  suppuration  sometimes  is 
arrested,  and  always  much  suffering  i?  prevented. 

To  Reduce  Suppuration. — During  the  progress  of 
a  carbuncle  it  is  advisable  to  administer  a  centigram 
(1-6  grain)  of  calcium  sulphide  every  hour  during  the 
height  of  the  fever  and  discomfort;  and  about  25  eg.  (1-2 


124  SURGICAL  THERAPEUTICS 

grain)  four  times  a  day  later  on.  It  seems  to  prevent 
the  formation  of  new  foci  as  well  as  to  reduce  the  amount 
of  local  inflammation,  quickly  liquefying  the  central  mass 
and  promoting  the  formation  of  healthy  granulations. 
It  is  claimed  that  if  given  before  suppuration  begins  the 
process  is  arrested,  and  a  hard  lump  forms  at  the  site  of 
streptococcus  infection — a  lump  which  disappears  in  a 
few  days  without  suppurating. 

CARCINOMA 

Defined  as  "a  malignant  tumor  characterized  by  a 
network  of  connective  tissue  whose  areolae  are  filled 
with  cell-masses  resembling  epithelial  cells".  (Gould). 
According  to  variation  hi  location  cancer  appears  under 
several  distinct  types. 

Alveolar. — One  with  an  alveolar  structure,  i.  e., 
little  pockets,  or  cysts,  filled  with  cancer-cells. 

Carcinoma  Taberosum. — Scirrhus  in  which  the 
nodules  are  of  very  large  size.  Rare. 

Benign  tumors  sometimes  undergo  a  cancerous  change, 
or  "degeneration;"  their  names  being  added  to  carcinoma, 
thus,  adenocarcinoma,  etc. 

Every  tumor  suspected  of  malignancy  should  be 
removed,  particularly  in  the  breast.  Only  in  early  excis- 
ion is  there  hope  of  cure;  decidedly  applicable  to  cancer 
of  the  uterus. 

If  consent  can  not  be  secured  to  early  removal,  burn- 
ing is  next  desirable:  preferably  with  the  Paquelin  cautery. 
This  is  especially  useful  for  superficial  epitheliomata. 

Pastes  (Marsden's,  Cauquoin's  and  others)  do  the 
same  thing  as  the  Paquelin  but  take  weeks  to  accomplish 
what  the  Paquelin  does  in  five  minutes,  and  are  very  pain- 
ful; many  times  unsatisfactory. 

The  x-ray  may  be  used  for  cases  too  far  advanced  for 
operation,  for  superficial  growths  and  ulcerations  and 


CARIES  125 

for  recurrent  growths  after  removal.  It  must  never  be 
used  as  the  treatment  of  choice  in  any  case  amenable  to 
operative  treatment. 

Radium  has  given  no  cures  as  yet.  Like  the  Roent- 
gen ray,  however,  its  use  gives  surprising  relief  from  pain, 
retards  the  growth  and  helps  sustain  the  patient. 

Tonics  and  stimulants  are  indicated  always. 

Morphine  must  be  given  in  inoperable  carcinoma — • 
to  any  extent  needed  to  alleviate  pain.  It  is  very  repre- 
hensible to  withhold  opiates  in  hopeless  cases  on  merely 
sentimental  grounds.  [See  "Cancer."] 

Colloid. — A  form  found  in  the  alimentary  canal, 
uterus,  peritoneum,  etc.,  in  which  the  delicate  connec- 
tive-tissue stroma  is  filled  with  colloid  material,  i.  e.,  a 
jelly-like  material  thicker  than  mucus,  filling  the  alveoli. 

Encephaloid. — A  type  of  rapid  growth,  made  up  of 
a  small  amount  of  stroma  and  large  alveoli,  with  a  greater 
number  of  cells  and  blood-vessels  than  the  other  varieties. 

Epithelioma. — A  carcinoma  of  skin  or  mucous  mem- 
brane. 

Lipomatotts. — One  which  contains  cells  infiltrated 
with  fat. 

Medullary. — Another  name  for  encephaloid. 

Melanotic. — One  in  which  the  cells  are  filled  with 
pigment,  sometimes  until  appearing  almost  black. 

Scirrhus. — A  hard,  slow-growing  cancer,  most  often 
found  in  the  breast,  consisting  of  a  stout,  fibrillated  stroma, 
closely  filled  with  large,  nucleated  cells. 

CARIES 

Necrosis  of  bone  may  follow  injury  if  there  be  infection 
by  pus-germs  or  by  tuberculosis.  The  inflammatory 
process  may  be  so  slow  as  to  warrant  the  expression 
"chronic,"  the  inflammation  being  followed  by  rarefica- 
tion  or  absorption  of  much  of  the  bony  tissue;  and  usually 


126  SURGICAL  THERAPEUTICS 

succeeded  by  formation  of  pus.  Sometimes  as  a  result 
of  a  severe  blow  a  part  of  the  bone  is  splintered  off 
(spicula)  in  such  a  way  that  its  nutritive  arteries  are  all 
ruptured;  in  which  case  molecular  death  occurs — followed 
later  by  pus-infection  in  most  cases. 

When  the  necrosis  is  due  to  tuberculosis  the  con- 
dition is  described  as  caries  fungosa,  the  sequestrum 
or  point  of  absorption  being  covered  with  granulations 
which  grow  from  the  inner  surface  of  the  cavity. 

Occasionally  instead  of  the  tuberculous  cavity  being 
filled  with  pus  there  is  found  a  condition  known  as  caries 
sicca:  a  dry  necrosis  with  obliteration  of  the  joint,  accom- 
panied by  sclerosis  and  concentric  atrophy  of  the  articu- 
lar extremity  of  the  joint. 

In  most  cases  of  caries  there  is  nothing  to  be  done  except 
to  cut  down  upon  the  affected  part,  remove  by  curettage 
or  otherwise  all  of  the  dead  bone,  pack  with  iodoform 
gauze  and  cause  the  cavity  to  close  by  healthy  granula- 
tions. The  earlier  this  can  be  done  the  better  the  ending. 

The  only  exceptions  to  this  rule  of  practice  are,  per- 
haps, destructive  osteitis  of  the  spine  (Pott's  disease) 
and  destructive  tuberculosis  of  the  hip  (hip-joint  disease). 
Even  in  these  cases  operation  is  sometimes  advisable; 
but  the  results  are  usually  deplorable  and  lead  to  cen- 
sure of  the  operator. 

Caries  of  the  Acromion. — This  is  very  rare.  Treat 
by  cureting  and  packing,  avoiding  opening  the  shoulder- 
joint.  Weak  joint  is  to  be  predicted. 

CARTILAGE:    DISEASES  OF 

Chondralgia. — Pain  in  or  about  a  cartilage  is  always 
suggestive  of  a  tuberculous  focus;  but  then  it  is  a  dull  ach- 
ing, while  chondralgia  is  acute,  sharp,  like  neuralgic  pains 
elsewhere.  The  treatment  is  the  same  as  for  neuralgia: 
anodynes  temporarily  (acetanilid,  codeine,  etc.)  with  strych- 


CATGUT:  IODINE  127 

nine  and  iron  to  improve  the  general  condition.  In  unyield- 
ing cases  chondrectomy  has  been  practised;  but  excision 
must  be  reserved  as  the  dernier  ressort. 

Chondritis. — Inflammation  of  a  cartilage  can  hardly 
be  differentiated  from  synovitis  (which  see). 

Chondromyxoma. — A  tumor  made  up  of  cartilaginous 
cells  (chondroma)  with  also  mucous  elements  present 
(myxoma).  Treatment:  excision. 

Chondrosarcoma. — A  tumor  of  mixed  cartilaginous 
and  sarcomatous  tissues.  Early  removal. 

CASTOR  OIL:  TO  RENDER  PLEASANT 

Some  surgeons  insist  that  nothing  can  take  the  place  of 
castor  oil  as  an  easy  purge  both  before  and  after  opera- 
tion. To  them  this  method  of  disguising  its  taste  (advised 
by  Carleton)  will  be  of  interest: 

Vanillini grs.  20 

Olei  menth.  pip dr.     i 

Saccharini drs.  i  1-2 

Alcoholis  ozs.  3 

Tinct.  persionis oz.       1-2 

Olei  ricini,  q.  s.  ad gal.      1-2 

Dissolve  the  vanillin,  oil  of  peppermint  and  saccharin  in 
the  alcohol.  Add  the  tincture  of  cudbear  to  the  oil  and 
shake  thoroughly.  Finally  unite  the  two  mixtures.  This 
mixture  looks  well,  tastes  well  and  is  pleasant  to  take. 

CATGUT:    IODINE 

Catgut  prepared  by  the  iodine  method  is  rapidly  gain- 
ing in  popularity  among  many  operators.  The  advantages 
claimed  for  it  are:  (i)  If  properly  handled  it  is  abso- 
lutely sterile.  (2)  In  the  course  of  its  preparation  it  does 
not  lose  any  of  its  tensile  strength.  (3)  It  is  readily  and 
simply  prepared  and  without  any  undue  expense.  (4)  It 
should  be  absorbed  completely,  but  only  after  it  has  served 


128  SURGICAL  THERAPEUTICS 

the  purposes  for  which  it  is  introduced.  The  method  of 
preparation  is  that  of  Bartlett:  the  gut  immersed  for  eight 
days  in  a  mixture  consisting  of  tincture  of  iodine,  one 
part,  proof  spirit,  fifteen  parts.  Bacteriological  investiga- 
tion shows  the  gut  to  be  then  sterile.  It  can  be  stored 
indefinitely  in  the  solution  in  which  it  is  prepared  without 
becoming  brittle.  It  is  soft  and  very  nice  to  handle. 

CERVICAL  RIBS 

A  peculiar  form  of  (usually)  bilateral  cervicobrachia* 
neuralgia  depends  upon  cervical  rib-formation.  The  pain 
starts  at  the  back  of  the  neck  and  radiates  into  the  arms, 
and  the  slightest  movement  or  touch  is  agony.  Outside 
of  the  attacks  passive  movements  of  the  head  to  right  or 
left  are  possible  without  pain,  but  bending  forward  causes 
pain  localized  in  the  cervical  ribs  and  shoulders.  The 
pains  appear  at  once  on  reclining,  and  the  patient  nearly 
always  has  learned  to  sleep  in  a  chair.  Large  doses  of 
morphine  have  scarcely  any  influence.  In  such  cases  the 
Roentgen  ray  will  show  a  cervical  rib  on  each  side,  corre- 
sponding to  the  seventh  cervical  vertebra.  The  trouble 
sometimes  does  not  manifest  itself  until  the  patient  begins 
to  have  the  senile  stoop — the  kyphosis  impinging  upon  the 
nerves.  Extension  treatment,  restoring  the  vertebrae  to 
their  natural  position,  has  done  good  service  and  rendered 
cervical  measures  superfluous;  in  others  removal  of  the 
rib  is  the  only  means  of  relief. 

CHANCRE 

This  term  was  formerly  used  to  express  any  sore  of 
venereal  origin.  Now  its  meaning  is  limited  to  the  initial 
lesion  of  syphilis.  It  is  also  called  "Hunterian  chancre," 
"hard  chancre"  (to  distinguish  it  from  chancroid,  the 
softer  sore).  It  should  be  remembered  that  the  chancre 
may  be  located  not  alone  upon  the  sexual  organs,  but  in 


CHANCROIDS  129 

the  mouth,  the  anus,  etc.  Authorities  upon  syphilis  now 
agree  that  there  is  nothing  gained  by  excision  or  other 
treatment  of  chancre;  as  soon  as  its  true  character  is  ascer- 
tained mercury  must  be  begun.  (See  "Syphilis".) 

CHANCROIDS 

These  are  contagious  ulcers,  inflammatory  in  type, 
not  syphilitic,  with  a  tendency  to  continue  indefinitely  and 
spread  by  infection  of  any  abraded  surface  receiving  their 
discharge.  They  are  not  serious  if  properly  treated  before 
large  areas  are  involved,  thus  forming  the  socalled  "ser- 
piginous  chancroid"  or  "phagedena." 

The  best  treatment  is:  Inject  a  few  minims  of  a 
2-percent  cocaine  solution;  the  needle  must  be  boiled  for 
twenty  minutes  after  using!  Then  burn  thoroughly  with 
Paquelin  cautery  at  bright-red  heat.  Besides  being  more 
efficacious  than  any  other  method  of  cure  this  possesses  the 
advantage  of  being  something  tangible  for  which  the  patient 
is  more  willing  to  pay  than  for  a  mere  application.  Some 
patients,  however,  object  to  the  cautery;  such  may  be 
treated  by  cauterization  with  nitric  acid,  applied  by  means 
of  a  little  absorbent  cotton  wound  around  a  wooden  tooth- 
pick; but  the  burning  must  be  thorough  to  insure  perfect 
cure.  If  the  cauterization  be  done  soon  enough  and  of 
sufficient  degree,  once  will  be  enough.  When  the  ulcerated 
surface  is  very  extensive,  cocainization  should  not  be  at- 
tempted; the  work  ought  to  be  done  with  the  patient  in 
full  surgical  narcosis. 

Formerly  Ricord's  paste  was  much  used.  Its  composi- 
tion is:  sulphuric  acid  with  enough  powdered  charcoal 
added  to  make  a  thick  paste.  This  is  applied  to  the  ulcer 
freely.  After  a  few  days  the  charcoal  drops  off,  leaving 
a  healthy,  granulating  surface  if  the  acid  has  done  its 
desired  duty.  It  is  painful,  whereas  the  cauterization  by 
Paquelin  cautery  is  attended  by  singularly  little  pain. 


130  SURGICAL  THERAPEUTICS 

After  the  burning,  or  after  the  paste  has  dropped  off, 
a  simple  antiseptic  ointment  may  be  applied.  lodoform 
is  much  employed  by  genitourinary  men,  but  on  account 
of  its  unpleasant  odor  other  iodine  salts  of  bismuth  or 
calomel  may  be  substituted.  A  good  formula  is: 

Bismuth  subiodide 8.0  (drs.  2) 

Vaseline 32.0  (oz.    i) 

This  is  to  be  applied  three  or  four  times  a  day. 

When  the  patient  is  in  excellent  health  and  the  chan- 
croid a  merely  superficial  ulceration,  burning  may  some- 
times be  omitted.  In  such  cases  the  ulcer  must  be  cleaned 
once  daily  by  hydrogen  dioxide,  full  strength,  dried  care- 
fully and  dusted  with  a  powder  consisting  of  equal  parts 
of  bismuth  subiodide  and  boric  acid.  If  there  be  an 
unusual  amount  of  discharge  tannic  acid  may  be  added; 
thus: 

Bismuth  subiodide     8.0  (drs.  2) 

Boric  acid 8.0  (drs.  2) 

Tannic  acid    4.0  (dr.    i) 

A  little  of  this  may  be  applied  three  or  four  times  a  day. 

The  chief  objection  to  this  mild  course  of  treatment 
is  the  constant  danger  of  the  trouble  suddenly  spreading 
and  the  even  greater  one  of  the  formation  of  buboes.  So 
long  as  there  is  a  trace  of  the  chancroidal  poison  left  in 
the  ulcer  these  dangers  persist;  therefore  the  more  energetic 
method  is  always  the  safest,  and  in  the  end  is  the  speediest 
way  of  cure.  And  it  is  imperative  whenever  a  chancroid 
previously  doing  well  suddenly  begins  to  spread. 

Sometimes  when  first  seen  the  tissues  around  the  chan- 
croid are  quite  hard,  tender  and  inflamed.  It  is  then  best 
to  put  the  patient  to  bed  and  use  hot,  antiseptic  fomenta- 
tions: cloths  wrung  out  of  hot  solution  of  phenol,  5  percent; 
or  one  dram  of  nitric  acid  to  the  pint  of  water  may  be  used 
instead — the  growth  of  all  pathogenic  bacteria  is  inhibited 
by  acids. 


CHILBLAINS  131 

Buboes. — When  chancroidal  buboes  form  the  glands 
should  be  protected  by  a  gauze  pad  applied  with  slight 
pressure  of  bandage.  When  the  glands  continue  to  enlarge 
they  may  be  painted  with  iodine  once  or  twice;  and  if 
they  become  hot  and  painful  lead  and  opium  wash  may 
be  applied.  As  soon  as  suppuration  is  detected  the  abscess 
must  be  freely  opened  and  treated  just  as  any  other  abscess. 
If  it  assume  a  chancroidal  or  phagedenic  character  it  must 
be  managed  just  like  the  original  chancroid.  (See  "Bubo".) 

Phagedena. — When  the  chancroid  extends  rapidly, 
with  alarming  destruction  of  tissue,  free  cauterization  must 
be  done  immediately.  A  few  hours'  delay  may  mean  ex- 
tensive sloughing,  necrosis  extending  to  the  thighs  or  to 
fatal  perforation  of  the  abdominal  walls  (occurring  in  the 
worst  neglected  cases).  Every  part  of  the  ulcer  must  be 
burned — every  little  nook  and  earner,  every  sinus  laid 
bare.  The  extensively  charred  surface  must  then  be 
treated  as  any  other  burn,  i.  e.,  by  antiseptics  and  exclusion 
of  air.  After  it  is  found  that  the  sloughing  has  been  ar- 
rested the  wound  should  be  dressed  as  rarely  as  possible, 
as  each  manipulation  interferes  with  granulation. 

To  weakened  patients  good  food  and  strong  tonics  must 
be  given — iron,  quinine  and  strychnine  being  best. 

CHILBLAINS 

A  good  application  to  chilblains  is  tincture  of  chloride 
of  iron,  full  strength,  at  bedtime.  Perhaps  a  better  treat- 
ment is  to  bathe  the  feet  in  hot  water  with  a  tablespoonful 
of  salt  added  to  each  quart;  dry  carefully  and  rub  in  this 
ointment: 

Menthol i.o  (grs.  15) 

Ichthyol 4.0  (dr.      i) 

Vaseline 32.0  (oz.      i) 

In  the  morning  a  simple  footbath  with  soap  and  water 
should  be  taken.  In  three  or  four  davs  the  trouble  should 


132  SURGICAL  THERAPEUTICS 

entirely  disappear  instead  of  being  a  source  of  annoyance 
all  winter. 

An  ointment  of  one  part  of  chlorinated  lime  and  nine 
parts  of  petrolatum  is  very  useful  in  chilblains.  It  often 
quickly  cures  the  most  obstinate  cases. 

A  celebrated  plaster  for  the  cure  of  chilblains  is  "De 
Rheim's  plaster;"  it  has  this  composition: 

Capsicum  pods 32.0  (oz.    i)  . 

Strong  alcohol 64.0  (ozs.  2) 

Macerate  for  several  days  and  add 

Mucilage  of  acacia 64.0  (ozs.  2) 

This  is  to  be  well  stirred  and  brushed  over  sheets  of  silk 
or  tissue-paper  and  applied  to  the  chilblain,  the  skin  over 
which  must  be  unbroken,  however. 

CHOLANGITIS 

Inflammation  of  a  bile  duct  is  rarely  to  be  distinguished 
from  cholecystitis,  there  being  the  same  ague-like  chill, 
fever,  sweating  and  jaundice  which  accompany  the  more 
extensive  trouble;  indeed  it  is  doubtful  if  even  the  medical 
examiners  of  the  Civil  Service  Commission  can  make  other 
than  a  theoretical  differential  diagnosis.  But  it  matters 
not — the  therapy  is  the  same.  (See  "Cholecystitis".) 


Inflammation  of  the  gall-bladder  is  almost  always  due 
to  infection  of  an  abraded  surface  by  the  bacillus  coli 
communis,  so  the  spilling  of  a  few  drops  of  pus  during 
operation  is  not  greatly  to  be  feared,  the  healthy  peritoneum 
can  usually  take  care  of  much  pus  of  such  origin;  but  it 
may  also  originate  from  infection  by  typhoid  bacilli,  by 
those  of  epidemic  influenza  and  by  the  two  chief  pus- 
producers:  staphylococci  and  streptococci.  The  occurrence 
of  jaundice  is  a  mere  incident — not  more  than  ten  percent 
of  all  gallstone  cases  have  jaundice,  though  occlusion  of 


CHOLECYSTITIS  133 

the  cystic  duct  by  gallstone  is  an  almost  constant  accom- 
paniment of  cholecystitis,  icterus  appearing  when  the 
common  duct  is  closed  either  by  stone  or  inflammatory 
swelling.  The  relation  of  gallstones  to  cholecystitis  has 
not  been  definitely  determined;  certain  it  is  that  calculi 
often  form  as  the  result  of  a  cholecystitis  which  does  not 
go  on  to  abscess-formation  because  the  duct  is  not  clogged; 
and  equally  sure  is  it  that  the  stones  later  may  so  injure 
the  mucosa  that  secondary  infection  occurs  with  the  forma- 
tion of  abscess  of  the  most  threatening  character.  The 
treatment  to  be  adopted,  then,  must  depend  upon  the  stage 
to  which  the  inflammation  has  progressed:  that  of  a  simple, 
non-obstructive  cholecystitis  differing  materially  from  that 
indicated  in  an  abscess  of  the  gall-bladder.  It  is  in  the 
treatment  of  a  non-suppurative  cholecystitis,  perhaps  with 
a  temporary  blocking  of  the  common  duct,  and  its  conse- 
quent icterus  ("catarrhal  jaundice"  as  it  is  frequently 
called),  that  the  most  brilliant  results  are  obtained  by 
internal  medication;  with  the  claim  that  "gallstones"  may 
be  "cured"  without  operation.  The  truth  is  that  a  gall- 
stone in  a  normal  gall-bladder  amounts  to  no  more  than  a 
piece  of  gum  in  a  healthy  mouth!  By  proper  therapy  the 
majority  of  cases  of  cholecystitis  may  be  cured  and  the 
unremoved  stone  causes  no  further  trouble  perhaps  for 
many  years  or  always.  This  proper  treatment  consists  in 
the  use  over  a  long  period  of  time  of  sodium  succinate, 
which  if  persisted  in  will  prevent  recurrences  of  the  attacks. 
The  paroxysms  may  usually  be  relieved  by  glonoin,  hyoscy- 
amine  and  strychnine.  In  very  severe  cases  the  H-M-C 
combination  is  most  effective. 

Cure  of  Cholecystitis. — Most  surgeons  experienced 
in  surgery  of  the  gall  tract  now  know  that  simple  removal 
of  gallstones  does  not  cure  all  the  trouble  in  most  cases. 
Dr.  Hugh  Taylor,  of  Richmond,  in  a  good  article  entitled 
"The  Scope  of  Surgery  in  Bile-Duct  Infections, " remarks : 


134  SURGICAL  THERAPEUTICS 

"cholecystostomy  removes  the  gallstones,  but  in  the  re- 
corded experience  of  many  does  not  cure  the  patient.  Why  ? 
Because  it  does  not  cure  the  cholangitis  and  cholecystitis. 

Cholecystectomy  often  leaves  an  infectious  inflammation 
involving  the  cystic,  common  or  hepatic  ducts  and  their 
ramifications.  More  and  more  the  conviction  has  been 
forced  that  even  hi  uncomplicated  cases  removal  of  the 
gallstones  does  not  give  satisfactory  end-results  because 
we  have  only  eliminated  one  of  the  sequences  and  not  the 
disease.  A  study  of  this  subject  at  the  hands  of  those 
whose  opinions  merit  our  greatest  consideration  impresses 
the  fact  that  the  key  to  success  is  drainage  (by  cholecystos- 
tomy or  through  the  hepatic  or  common  duct),  prolonged 
drainage,  until  the  infections  in  the  gall-bladder  and  ducts 
have  subsided."  Dr.  Maurice  Richardson  tersely  puts  it: 
"  From  study  and  experience,  therefore,  I  am  led  to  the  con- 
clusion that  the  essential  thing  in  the  surgery  of  the  biliary 
tract  is  full,  free  drainage,  allowed  to  persist  until  it  closes 
spontaneously."  Moynihan,  in  his  work  on  "Abdominal 
Operations,"  page  526,  writes:  "The  great  principle  which 
has  to  be  carried  out  in  all  gallstone^  surgery  is  drainage," 
drainage  to  prevent  leaking,  "and  cure  that  condition  of  the 
mucosa  (stone-forming)  which  was  responsible  in  the 
first  instance  for  the  formation  of  gallstones."  There- 
fore cases  not  yielding  promptly  should  be  operated  on. 

Cholecystitis:  Therapy  of. — Bilein  is  helpful  in 
inflammation  of  the  gall-bladder  and  for  gallstones 
not  subjected  to  surgical  treatment.  It  consists  of  the 
alkaline  salts  of  the  bile-acids,  the  active  agents  of  the  bile; 
The  dose  is  from  one  to  three  centigrams,  four  times  a  day 
(1-8  to  1-2  grains).  It  is  often  given  in  combination  with 
an  equal  amount  each  of  calomel  and  podophyllin,  making 
an  active  hepatic  stimulant  and  socalled  cholagog.  When 
given  alone  it  should  be  followed  by  a  saline  laxative. 
Of  course  for  entire  arrest  of  symptoms  it  is  important 


CHOLECYSTITIS  135 

that  the  patient  be  given  a  long  course  of  treatment  with 
sodium  succinate — for  a  year  if  necessary. 

Treatment  After  Cholecystostomy, — After  the  gall- 
bladder has  been  opened  and  drainage  established  the 
external  layers  of  gauze  and  cotton  must  be  changed  as 
often  as  they  become  soaked  with  bile,  blood  or  mucus: 
about  every  four  to  six  hours  the  first  day  and  twice  daily 
thereafter;  but  the  layers  of  gauze  next  the  wound  should 
not  be  disturbed  until  the  third  or  fourth  day,  when  the 
drainage  may  be  withdrawn.  Next  day  the  gall-bladder 
may  be  washed  out  with  peroxide  of  hydrogen,  but  no 
water;  a  small  strand  or  wick  of  gauze  may  be  inserted 
into  the  opening,  but  care  must  be  taken  that  it  does  not 
slip  into  the  gall-bladder;  in  one  of  my  cases  a  long  piece 
of  iodoform  gauze  was  carried  in  the  gall-bladder  more 
than  two  years  (with  no  discomfort  save  the  annoyance  of 
a  fistula  which  would  discharge  a  little  bile  and  mucus 
every  few  weeks).  After  gallstone  disease  the  gall-bladder 
should  be  drained  three  weeks,  great  care  being  exercised 
not  to  infect  with  staphylococcus  or  streptococcus,  i.  e., 
plenty  of  bichloride  gauze  (i  in  2000)  must  be  used  at  each 
dressing,  and  hands  and  syringe  must  be  sterile;  it  is  best 
to  use  rubber  gloves  in  changing  the  dressings,  as  they  may 
be  rendered  sterile  very  easily.  Internally  calomel  should 
be  given  as  early  as  the  third  day,  and  thereafter  the  bowels 
kept  loose  by  podophyllin,  or  saline  laxatives. 

Typhoid  a  Cause  of  Cholecystitis. — Inflammation 
of  the  gall-bladder  due  to  infection  by  the  typhoid  bacil- 
lus is  quite  common  and  may  lead  to  abscess.  In  most 
cases  of  cholecystitis,  however,  there  is  mixed  infection 
of  the  typhoid  bacillus  and  colon  bacillus  or  typhoid 
bacillus  and  staphylococcus.  The  abscess  may  not 
develop  until  many  months  after  the  typhoid  fever.  The 
Eberth  bacilli  may  be  present  not  only  in  the  contents 
of  the  gall-bladder  but  also  in  its  walls,  there  sometimes 


136  SURGICAL  THERAPEUTICS 

being  necrotic  patches  caused  by  the  bacilli,  and  rarely 
perforative  peritonitis  occurs  from  this  origin.  There 
can  be  little  doubt  that  gallstones  owe  their  origin  to 
infection  of  the  gall-bladder  by  the  germs  of  typhoid. 
Strange  to  say,  a  serious  cholecystitis  may  originate  from 
infection  with  typhoid  and  colon  bacilli,  go  on  its  course 
without  symptoms  other  than  trifling  discomfort,  and 
end  in  perforation  before  the  patient  sends  for  a  physi- 
cian. Rarely  a  tumor  is  known  to  be  present  (a  dis- 
tended gall-bladder  containing  bile  mixed  with  mucus 
and  pus),  but  there  will  be  little  complaint  until  rupture 
occurs,  with  profound  shock  and  intense  and  sudden 
pain,  the  latter  generally  at  the  inguinal  region. 

Opening  the  abscess  and  establishing  free  drainage 
constitute  the  proper  treatment. 

CHORDEE 

During  gonorrhea  painful  erection  is  liable  to  occur, 
the  penis  being  bent  downward  by  the  unyielding  inflamed 
urethra.  Application  of  ice  affords  the  quickest  relief, 
but  it  is  objectionable  because  the  reaction  following  it 
may  lead  to  worse  chordee.  Wrapping  very  tightly  with 
a  narrow  bandage,  beginning  at  the  glans,  is  better,  fol- 
lowed by  two  grams  (30  grains)  each  of  potassium  bro- 
mide and  chloral  in  4  ounces  of  water,  given  by  the 
rectum. 

Prevention  of  Chordee. — For  the  prevention  of 
chordee  during  the  acute  stage  of  gonorrhea,  gelseminine 
is  worthy  of  trial.  A  tablet  of  a  half  milligram  (1-134 
grain)  may  be  given  every  two  hours  during  the  day  for 
several  days;  with  it  should  be  given  a  tablet  of  caulophyllin 
containing  one  centigram  (gr.  1-6).  The  urine  should  be 
kept  bland  and  unirritating  by  the  use  of  sandalwood  oil 
or  copaiba,  or  by  lithium  benzoate,  one  decigram  (or  about 
two  grains)  four  or  five  times  a  day.  Large  quantities 


CIRCUMCISION  137 

of  water  should  be  drunk  and  alcohol  scrupulously  excluded 
until  the  severe  stage  of  clap  has  passed. 

CICATRICIAL  DEFORMITIES 

Deformities  due  to  contraction  of  scar-tissue  are  gen- 
erally best  left  alone.  Rarely  the  scar  can  be  dissected 
out  and  healthy  skin  brought  from  a  nearby  part  to  cover 
the  denuded  area.  If  done  with  such  perfect  asepsis  as 
to  secure  healing  by  primary  union  the  operative  pro- 
cedure may  succeed;  but  if  suppuration  occur  the  sec- 
ondary scar  may  be  worse  than  the  original. 

CIONITIS 

Inflammation  of  the  uvula  is  not  very  common,  but 
gives  much  discomfort  when  it  does  occur.  Perhaps  the 
best  application  is  a  saturated  solution  of  potassium  chlor- 
ate with  a  little  tincture  of  hydrastis  added.  It  may  be 
used  as  a  gargle.  When  the  attacks  are  often  repeated, 
as  may  be,  the  uvula  should  be  amputated,  about  two- 
thirds  being  removed.  The  hemorrhage  may  be  checked 
by  using  antipyrin  powder  on  a  pledget  of  cotton;  or  if 
excessive,  by  ligature.  Removal  is  especially  indicated 
if  there  be  cionoptosis:  prolapse  of  the  uvula. 

CIRCUMCISION 

This  must  be  performed  in  every  case  of  balanitis' 
in  concealed  chancre,  in  all  chancroids  when  the  glans 
cannot  be  readily  exposed,  in  paraphimosis  and  most 
cases  of  phimosis.  Many  nervous  symptoms  of  child- 
hood depend  upon  or  are  aggravated  by  retained  smegma 
and  adherent  prepuce;  many  inveterate  masturbators 
owe  their  trouble  to  the  same  cause — so  every  boy's  pre- 
puce ought  to  be  examined  from  time  to  time  and  early 
circumcision  made  in  every  case  where  there  is  any  ser- 
ious trouble  present.  Practically  all  doctors  are  too 
careless  about  this  matter. 


138  SURGICAL  THERAPEUTICS 

CONDYLOMA 

This  condition  (known  also  as  moist  wart,  fig-wart, 
cauliflower  excrescence  and  venereal  wart)  is  properly 
designated  -verruca  acuminata.  It  is  a  warty  growth 
which  occurs  in  parts  subjected  to  maceration  in  sweat, 
or  bathed  in  venereal  secretions  or  mucous  discharges, 
like  the  genital  and  anal  folds  and  the  vulva.  The  warts 
may  be  flat  or  acuminate,  whitish,  pinkish  or  reddish, 
pedunculated  or  sessile;  usually  they  are  more  or  less 
associated  groups  or  masses  of  vegetations  smeared  with 
a  nasty  secretion.  They  bleed  on  manipulation. 

Genital  Condylomata. — Condylomata  of  the  gen- 
italia  are  most  easily  removed  by  use  of  the  Paquelin 
cautery.  But  sometimes  patients  object  to  anything 
which  can  be  regarded  as  an  operation  even  though  done 
under  local  anesthesia.  In  such  a  case  the  growths  may 
be  touched  with  pure  acetic  acid,  without  great  pain; 
and  the  patient  directed  to  keep  the  affected  parts  con- 
stantly moist  with  a  solution  of  one  dram  of  the  acid  to 
a  pint  of  water. 

Acetic  acid,  pure 4.00 

Water 500.00 

Under  this  treatment  the  warty  growths  will  speedily  and 
painlessly  disappear.  When  the  affected  area  is  extensive, 
excision  and  cauterization  are  indispensable. 

CONJUNCTIVITIS 

It  is  now  pretty  generally  agreed  among  ophthalmic 
surgeons  that  protargol  is  a  more  satisfactory  agent  than 
either  argyrol  or  silver  nitrate  for  the  treatment  of  acute 
mucopurulent  conjunctivitis,  and  that  argyrol  is  better 
than  silver  nitrate.  Protargol  is  perfectly  safe  up  to 
33  percent,  and  may  probably  be  used  in  even  stronger 


CONVALESCENCE  139 

solutions.  Its  application  causes  much  less  pain  than 
silver  nitrate,  but  more  than  argyrol.  Silver  nitrate  in 
strong  solutions  is  a  very  dangerous  agent. 

CONSTIPATION  FROM  MECHANICAL  CAUSES 

Gant  calls  attention  to  the  necessity  for  considering 
the  mechanical  causes  of  constipation,  which  are  often 
overlooked,  and  the  trouble  attributed  to  the  better-known 
causes.  In  this  class  of  cases,  no  matter  how  much  time 
is  spent  in  trying  to  educate  the  patient  and  improve  his 
general  condition,  it  is  impossible  to  secure  the  desired 
result  until  the  obstruction  is  removed.  To  accomplish 
this  it  is  usually  necessary  to  resort  to  some  operative 
measure.  The  following  are  the  most  frequent  mechan- 
ical causes  of  constipation:  congenital  deformities,  which 
occur  oftener  in  the  rectum  and  at  the  anus  than  else- 
where in  the  gut;  extraintestinal  pressure,  from  uterine 
displacements,  tumors,  inflammatory  disease,  etc.,  which 
cause  constipation  by  compression;  strictures;  malignant 
and  nonmalignant  neoplasms;  foreign  bodies,  either 
swallowed  or  formed  within  the  gut;  fecal  impaction. 

CONVALESCENCE 

Iron  Tonic  for  Convalescents. — Patients  who  have 
lost  much  blood  often  do  better  during  convalescence  if 
given  arsenic  at  mealtime  and  a  good  iron  mixture  an  hour 
afterwards.  A  most  excellent  combination  is  the  following: 

Tincture  of  iron  chloride 10.0  (drs.    2  1-2) 

Dilute  acetic  acid 8.0  (drs.    2        ) 

Syrup 112.0  (ozs.    3  1-2) 

Whisky 384.0  (ozs.  12         ) 

Mix  thoroughly  and  add: 

Ammonium  carbonate 1.5  (grs.  20    ) 

Direct:  A  tablespoonful  one  hour  after  each  meal. 
Chemists  will  declare  this  is  an  "impossible"  prescription 


140  SURGICAL  THERAPEUTICS 

on  account  of  the  chemical  changes  which  take  place  on 
mixing.  But  if  the  bottle  be  corked  tightly  at  once  and 
kept  corked  between  doses  it  makes  the  most  agreeable 
liquid  iron-mixture  there  is,  patients  often  asking  for 
"another  bottle  of  that  nice  'wine'  tonic." 

Ntix  Vomica  Daring  Convalescence. — After  seri- 
ous operation  the  tongue  may  remain  covered  with 
a  pasty,  white  coating  for  many  days  after  all 
disturbance  from  the  surgical  work  has  subsided;  the 
appetite  being  a  little  slow  in  appearing.  This  does  not 
mean  chronic  sepsis,  even  of  mild  degree,  but  may  be 
ascribed  merely  to  the  stomachic  disturbance  which  is 
like  that  attending  cirrhosis  of  the  liver  when  the  condi- 
tion of  the  tongue  is  precisely  similar.  One  centigram 
(1-12  grain)  of  calomel  may  be  given  every  hour  until 
the  bowels  move  freely;  and  next  day  one  or  two  drops 
of  the  tincture  of  nux  vomica  in  half  of  a  glassful  of  water 
every  two  hours.  After  twenty-four  or  forty-eight  hours 
of  this  treatment  the  tongue  will  clean,  the  appetite  return 
and  the  general  condition  improve  rapidly.  This  is  of 
particular  interest  in  abdominal  section  without  drain- 
age where  the  conscientious  surgeon,  whatever  his  experi- 
ence, is  always  a  little  anxious  until  the  bowels  are  mov- 
ing freely  and  the  tongue  has  cleaned. 

The  Ideal  Tonic  for  Convalescents. — But  all 
things  considered  probably  the  best  tonic  medication  is 
to  be  procured  in  granule  form,  and  for  this  purpose  it 
is  hard -to  find  a  better  formula  than  the  "triple  arsenates 
with  nuclein."  Its  formula  is:  Strychnine  arsenate, 
gr.  1-134;  quinine  arsenate,  gr.  1-67;  iron  arsenate,  gr. 
1-67,  with  4  drops  of  nuclein  solution.  To  the  tonic 
properties  of  strychnine  and  quinine  are  added  the  blood- 
making  elements,  with  iron  and  arsenic,  with  the  cell 
stimulant,  nuclein,  which  is  particularly  useful  in  these 
cases.  If  the  appetite  is  pOor  give  quassin,  hydrastin 


CORNEAL  ULCERS  141 

if  the  mucosa  needs  stimulation,  while  if  the  gastric  secre- 
tions are  inactive  hydrochloric  acid  may  be  indicated. 
Attend  always  to  the  condition  of  the  bowel. 

Tonic  Daring  Convalescence. — The  prejudice  against 
pleasant  medicines  such  as  tablets,  granules,  elixirs,  etc., 
which  is  found  in  some  communities,  must  not  be  met  by 
a  flat  refusal  to  use  the  kind  of  medicines  to  which  the 
people  have  been  accustomed;  a  campaign  of  education  is 
best,  gradually  supplanting  the  nasty  by  the  nice.  In  every 
such  locality  will  be  found  individuals  who  demand  "bit- 
ters" to  be  taken  during  convalescence  from  operations, 
etc.  To  such  the  following  may  be  given — to  their 
entire  satisfaction. 

Dilute  nitrohydrochloric  acid 8.0 

Tincture  of  nux  vomica 4.0 

Compound  tincture  of  cardamon 64.0 

Compound  tincture  of  gentian 164.0 

Whisky 1 28.0 

Direct:  One  tablespoonful  before  each  meal.  It  cer- 
tainly makes  the  patient  eat. 

CORNEAL   ULCERS 

Every  ophthalmic  surgeon  will  probably  agree  with 
Jones  that  every  injury  of  the  cornea  should  be  assumed 
to  be  infected.  The  eye  should  be  promptly  irrigated 
with  a  saturated  solution  of  boric  acid,  or  bichloride  of 
mercury  solution,  one  in  four  thousand,  and  kept  as  nearly 
aseptic  as  is  possible  by  the  free  use  of  a  bichloride 
and  salt  ointment  containing  bichloride  of  mercury,  one- 
fifth  grain,  and  sodium  chloride,  one  grain,  to  vaseline. 
one  ounce.  If  pain  is  a  factor,  one  may  add  five  grains 
of  cocaine,  allowing  the  druggist  to  use  a  small  quantity 
of  liquid  albolene  better  to  enable  the  cocaine  to  dissolve. 
If  the  injury  is  as  much  as  twelve  hours  old  and  the  proper 
antiseptic  precautions  have  not  been  taken,  it  is  well  to 


142  SURGICAL  THERAPEUTICS 

touch  the  wound  with  tincture  of  iodine  applied  by  a 
few  shreds  of  absorbent  cotton  wound  around  a  small 
probe  or  smooth  wooden  toothpick.  All  applications 
to  the  cornea  being  painful,  a  previous  instillation  of  a 
four-percent  solution  of  cocaine  should  be  made. 

When  the  ulcer  has  declared  itself,  the  first  procedure 
is  to  curet  thoroughly  with  a  small-size.  Meyhoefer's  cor- 
neal  curet,  then  touch  with  tincture  of  iodine.  If  after 
twenty-four  hours  there  is  no  marked  improvement, 
cauterization,  either  with  carbolic  acid  after  the  same 
manner  as  the  application  of  iodine,  or  with  the 
actual  cautery,  should  be  thoroughly  done.  For  the 
latter,  the  suitable  instrument  is  Gruening's  cautery 
probe.  These  two  instruments  are  very  inexpensive 
and  should  be  in  the  office  of  every  country  doctor. 
Atropine  sulphate,  one  percent,  should  be  instilled  every 
four  hours  for  the  first  day,  then  twice  a  day.  Hot  appli- 
cations of  boric  acid,  a  teaspoonful  to  a  pint  of  water 
as  hot  as  can  be  borne,  bathing  the  eye  for  ten  minutes 
at  a  time,  every  hour,  are  very  beneficial.  A  shade  or 
smoked  glass  may  be  worn  to  shield  the  eye  from  light. 

The  cauterization  may  be  repeated  in  two  or  three 
days,  if  necessary;  often  one  application  suffices. 

CORNS 

Corns  are  divided  into  hard  and  soft— the  latter  being 
those  situated  between  the  toes  and  differing  from  the 
hard  variety  merely  by  being  softened  by  maceration.  The 
treatment  of  each  is  the  same:  First,  permanent  removal 
of  the  shoe  which  causes  the  pressure  and  friction,  and 
second,  application  of  salicylic  acid  in  some  manner.  To 
•relieve  the  suffering  from  inflammation  around  a  corn, 
or  that  from  "soft  corns,"  the  foot  should  be  bathed  in 
very  hot  water  for  a  half  hour;  then  dried  carefully  and  the 
surface  touched  with  saturated  solution  of  silver  nitrate. 


CYSTITIS  143 

The  inflamed  area  around  the  corn  may  be  surrounded 
by  a  piece  of  gauze  smeared  with  belladonna  ointment, 
covered  with  oiled  silk,  left  on  over-night.  The  burning 
is  to  be  repeated  every  fourth  or  fifth  evening.  For  or- 
dinary corns  this  may  be  ordered: 

Salicylic  acid 2.0  (grs.    30) 

Extract  of  cannabis  indica 0.5  (grs.     8) 

Collodion  16.0  (oz.    1-2) 

To  be  applied  every  night  with  a  camelshair  brush.  It 
often  irritates  a  little  for  two  or  three  days,  but  that  soon 
passes  away  and  a  cure  is  effected. 

Soft  Corns. — The  following  formula  is  useful: 

Acidi  salicylici   4.0  (dr.    i) 

Menthol 4.0  (dr.    i ) 

Olei  theobromatis    1 20.0  (ozs.  4) 

Apply  every  night  after  soaking  the  feet  in  warm  water. 

CRADLE 

In  surgery  the  arculus  or  cradle  is  very  useful  in  keep- 
ing bed-clothes  from  coming  in  contact  with  a  painful  part. 
It  is  easily  made  of  wire  or  of  hickory  branches. 


It  is  particularly  useful  for  bruises  or  wounds  of  the 
extremities,  but  may  be  made  large  enough  to  keep  the 
bed-clothes  from  the  abdomen  in  appendicitis,  etc. 

CYSTITIS 

Acute  Cystitis. — Acute  cystitis  may  arise  from  gonor- 
rhea, from  infection  by  dirty  sounds  or  catheters  and 
from  injury.  For  the  reduction  of  the  fever  which  is  pres- 


144  SURGICAL  THERAPEUTICS 

ent  at  the  beginning,  aconite  is  the  best  remedy,  either  as 
the  tincture  or  as  a  granule  of  aconitine :  one-half  milligram 
(gr.  1-134)  every  hour  or  two  until  the  temperature  drops 
satisfactorily.  For  the  pain  half  a  tablet  of  hyoscine- 
morphine-cactin  may  be  given  every  two  or  three  hours 
by  the  mouth.  Sodium  benzoate  in  dosage  of  one  centi- 
gram (gr.  1-6)  every  two  or  three  hours  gives  good  results, 
either  alone  or  in  combination  with  phenol  salicylate  two 
decigrams  (3  grains).  These  should  not  be  administered 
until  after  the  temperature  has  come  down  to  near  the 
normal.  While  the  aconitine  is  being  given  to  check  the 
fever  large  quantities  of  water  should  be  drunk,  with  good 
doses  of  potassium  citrate.  During  the  height  of  the  at- 
tack an  exclusive  liquid  diet — preferably  milk — is  to  be 
ordered.  Occasionally  the  suffering  is  so  great  from  the 
irritation  at  the  neck  of  the  bladder  that  good  sleep  is  im- 
possible. A  suppository  of  belladonna  and  extract  of 
opium  in  cacao  butter,  at  bedtime,  will  give  a  good  night's 
rest: 

Extract  of  belladonna    o.i 

Extract  of  opium .0.2 

Cacao  butter q.  s. 

Mix  and  make  four  suppositories.  Each  morning  after 
this  is  used  an  effervescing  saline  laxative  (Abbott's)  must 
be  taken,  followed  by  an  enema  after  the  bowels  are  moved. 
A  few  days'  rest  in  bed  is  imperative. 

Cystitis:  Chronic* — A  very  distressing  sequel  to  any 
operation  in  which  the  bladder  has  to  be  catheterized  re- 
peatedly is  a  chronic  cystitis.  The  irritation  may  persist 
for  months  in  spite  of  the  most  energetic  treatment.  Prob- 
ably the  most  satisfactory  remedy  is  lithia;  it  may  be  given 
as  an  effervescent  tablet  in  a  glassful  of  water  three  times 
a  day  for  long  periods,  or  lithium  benzoate  may  be  used 
in  doses  of  one  or  two  decigrams  (one  grain  to  three 
grains)  every  four  hours  during  the  day  until  the  stomach 


CYSTIC  DISEASE  145 

rebels.  If  there  is  much  annoyance  from  having  to  urinate 
at  night  two  grams  of  potassium  bromide  with  a  teaspoon- 
ful  of  tincture  of  hyoscyamus  may  be  ordered  at  bed- 
time. To  some  patients  arbutin  (from  uva  ursi)  in  doses 
of  one  centigram  (gr.  1-6)  four  to  six  times  a  day  brings 
relief.  Others  are  benefited  by  half-gram  doses  of  phenol 
salicylate  (salol)  four  times  a  day.  Extreme  cases  demand 
irrigation  of  the  bladder  with  a  saturated  solution  of  boric 
acid  three  times  "a  week;  after  a  few  washings  it  is  wrell 
to  inject  a  dram  of  fluid  extract  of  hydrastis  in  two  ounces 
of  water,  at  the  end  of  an  irrigation  leaving  it  in  the  blad- 
der. As  a  rule,  the  less  local  treatment  the  better.  Two 
quarts  of  water  drunk  daily  will  do  much  toward  cure. 

For  Gonorheal  Cystitis.. — Of  decided  value  in  gon- 
orrheal  cystitis  is  arbutin  in  doses  of  five  grains  every  three 
or  four  hours.  In  cystitis  due  to  other  pyogenic  microor- 
ganisms it  is  soothing  but  not-  so  effective. 

Phenol  Salicylate  for  Cystitis. — One  of  the  most 
valuable  of  all  drugs  used  for  cystitis  is  salol  (salicylate  of 
phenol).  This  consists  of  about  6$-percent  salicylic  acid 
and  35-percent  phenol;  is  decomposed  slowly  in  the  intes- 
tine by  the  pancreatic  fluid  into  its  original  constituents; 
and  is  eliminated  through  the  urine  as  urate  of  salicyl, 
though  if  given  in  large  quantities  some  seems  to  pass 
into  the  bladder  unchanged.  In  five-grain  doses  every 
three  hours  it  effectually  prevents  decomposition  of  urine 
in  the  bladder  and  keeps  it  from  becoming  alkaline.  It 
cannot  be  continued  very  long  on  account  of  producing 
phenoluria.  "\Yhenever  the  urine  becomes  smoky,  boric 
acid  should  be  substituted  for  a  few  days. 

CYSTIC  DISEASE 

Cystalgia.— Pain  in  the  bladder  may  be  neuralgic,  but 
is  usually  due  to  stone,  to  infection  or  to  stricture.  (See 
"Irritable  Bladder.") 


146  SURGICAL  THERAPEUTICS 

Cystatrophia, — A  true  atrophy  of  the  bladder  is  rare, 
and  can  have  no  remedy.  Contracted  bladder  may  some- 
times be  helped  by  gradual  dilation,  the  best  means  being 
daily  irrigation,  each  day  adding  not  to  exceed  one  dram 
of  fluid  to  the  amount  injected  through  a  fountain  syringe. 
A  saturated  solution  of  boric  acid  is  best. 

Cystobtfbonocele. — This  is  the  name  applied  to  a 
hernia  of  the  bladder  through  the  inguinal  ring.  It  is 
chiefly  of  interest  in  that  it  sometimes  is  opened  by  mis- 
take for  the  hernial  sac — hence  should  always  be  borne 
in  mind  in  operations  for  incarcerated  inguinal  hernia  of 
the  direct  type.  It  is  cured  as  is  any  other  hernia :  by  clos- 
ure of  the  opening  by  sutures. 

CYSTS 

Cyst  adenoma* — An  adenoma  is  sometimes  found 
to  contain  cysts;  when  the  name  cystadenoma  is  given 
to  the  growth.  Treatment  is  the  same  as  adenoma 
(which  see). 

Cystocarcinoma. — A  cancerous  tumor  sometimes  un- 
dergoes a  cystic  degeneration  in  some  part,  when  it  is  called 
cystocarcinoma.  The  treatment  is  the  same  as  cancer 
(which  see). 

Dermoid  Cysts  are  congenital  tumors  which  con- 
tain bone,  teeth,  hair,  etc.,  occurring  chiefly  in  the  ovary, 
though  they  may  be  found  in  the  testicle,  the  abdominal 
wall,  etc.,  a  favorite  site  being  the  region  of  the  coccyx. 
Early  excision  is  advisable. 

Echinococcus  Cysts  are  those  found  in  various  tissues 
and  organs  of  the  body,  originating  from  the  larvae  of 
taenia  echinococcus,  the  tapeworm  of  the  dog,  which  are 
taken  into  the  stomach.  They  are  frequent  among  Ice- 
landers and  Esquimaux,  those  who  are  thrown  into  close 
company  with  dogs;  and  in  the  temperate  zone  are  occa- 
sionally met  in  those  who  eat  scraps  from  garbage-cans, 


DACTYLOLYSIS  147 

etc.  The  liver  is  perhaps  most  often  the  site  of  this  form 
of  trouble,  Glisson's  capsule  being  pushed  off  and  the 
parent-cyst  developing  daughter-cysts  until  almost  the  entire 
abdomen  is  filled.  The  only  treatment  is  incision,  thor- 
ough emptying  of  the  cyst,  cauterization  with  iodine  and 
phenol  (of  each  equal  parts)  and  packing;  allowing  the 
cavity  to  agglutinate  and  the  wound  to  close  by  granulation 
without  suppuration. 

Miillerian  Cysts  are  tumors  developing  in  the 
remnants  or  rudiments  of  the  inferior  (or  vaginal)  portion 
of  the  duct  of  Miiller,  and  containing  mucus  or  blood  or 
even  pus. 

Retention  Cysts  are  those  which  originate  in  the 
non-expulsion  of  the  secretion  of  a  gland,  by  reason  of 
the  closure  of  the  duct — as  sebaceous  cysts,  mucous  cysts, 
ranula,  etc.  Removal;  or  incision  and  cauterization. 

Wblffian  Cysts  are  those  which  develop  in  the 
inferior  vestiges  of  the  canal  of  Wolff.  They  are  found 
in  the  anterior  or  anterolateral  wall  of  the  vagina,  and 
are  sometimes  prolonged  toward  the  cervix  and  even  into 
the  lower  part  of  the  broad  ligament.  Extirpate.  1 

DACTYLITIS 

Inflammation  of  a  finger  or  toe  may  be  (i)  traumatic, 
(2)  rheumatic  or  (3)  syphilitic.  The  first  is  to  be  treated 
by  antiseptic  applications;  the  second  by  antirheumatic 
remedies;  the  third  by  iodides  and  mercury.  If  pus  forms 
it  must  be  evacuated  very  early  to  prevent  burrowing  along 
the  tendons  with  consequent  great  deformity.  It  is  easy 
to  open  and  easy  to  cure. 

DACTYLOLYSIS 

The  falling  off  of  a  finger  or  toe,  due  to  gangrene, 
leprosy,  Reynaud's  disease,  etc.,  is  a  very  rare  surgical 
accident.  Treatment  consists  merely  in  the  application 


148  SURGICAL  THERAPEUTICS 

of  antiseptic  dressings  to  the  stump  and  attention  to  the 
disease  which  is  the  cause  of  the  spontaneous  ampu- 
tation. 

DEPILATORY 

Most  of  the  liquid  depilatories  on  the  market  are  solu- 
tions of  barium  sulphide.  To  remove  the  hair  from  the 
downy  surface  of  a  woman's  skin  iodine-collodion  has  been 
used,  the  collodion  being  painted  on  the  part  a'nd  removed 
when  dry,  bringing  the  adhering  hairs  with  it.  The  fol- 
lowing formula  has  been  proposed: 

Tincture  of  iodine  (iini2) 3  parts 

Oil  of  turpentine 6  parts 

Castor  oil   8  parts 

Alcohol  (go-percent) 19  parts 

Collodion 100  parts 

This  is  painted  on  the  part  and  as  the  film  comes  off  the 
hairs  are  supposed  to  come  with  the  firm.  There  is,  how- 
ever, nothing  so  satisfactory  as  a  paste  formed  by  adding 
water  to  a  specially  prepared  barium  powder.  For  such 
the  following  is  a  good  formula: 

Barium  sulphide 25  parts 

Powdered  soap    5  parts 

Powdered  talc    35  parts 

Corn  starch 35  parts 

Perfume q.  s. 

One  teaspoonful  of  the  powder  is  made  into  a  paste  with 
three  teaspoonfuls  of  water  and  applied  to  the  parts  with 
an  ordinary  shaving  brush  in  a  moderately  thick  and  even 
layer.  After  four  to  five  minutes  the  parts  should  be  moist- 
ened with  a  sponge,  when,  after  another  five  minutes,  the 
hair  can  be  removed  by  washing  off  the  mass.  It  is  impor- 
tant to  use  barium  sulphide  in  as  fresh  a  condition  as  pos- 
sible; that  oxidized  by  exposure  to  air  should  not  be  em- 
ployed. 


ECZEMA  149 

DUSTING  POWDER:    RESORCIN  AS 

Rarely  from  an  infected  wound  there  is  too  free  dis- 
charge and  an  antiseptic  dusting  powder  is  desired.  A 
most  admirable  one  is: 

Resorcin i  part 

Boric  acid 20  parts 

Mix  thoroughly.  This  may  be  dusted  freely  on  the 
affected  surface.  It  is  much  more  pleasant  than  iodoform, 
yet  possesses  all  the  antiseptic  value  of  that  malodorous 
powder. 

DYSPEPSIA:    SURGICAL  CURE  OF 

S£>me  marvelous  cures  are  being  reported  of  apparently 
incurable  chronic  "indigestion"  by  removal  of  gallstones 
previously  unsuspected  by  the  victim.  Cases  dependent 
upon  gastric  or  duodenal  ulcers  are  also  relievable  by  a 
not  dangerous  operation. 

DYSPHAGIA:  BROMIDES  FOR 

Occasionally  a  child  is  brought  to  the  surgeon  for 
presumed  stricture  of  the  esophagus — "congenital  spas- 
modic stricture"  it  may  have  been  pronounced.  Investi- 
gation reveals  the  queer  fact  that  since  birth  the  little 
patient  has  been  able  to-  swallow  solid  food  but  that  every 
attempt  to  drink  any  fluid  is  followed  by  choking:  violent 
expulsive  efforts,  coughing,  even  strangling.  The  most 
careful  examination  reveals  nothing  in  the  way  of  organic 
cause — it  is  purely  nervous.  A  few  days'  treatment  with 
elixir  of  bromide  of  potassium  will  almost  invariably  relieve 
the  trouble.  It  may  be  necessary  to  repeat  the  medicine 
every  three  or  four  weeks  for  some  months  before  a  com- 
plete cure  is  effected. 

ECZEMA 

The  tendency  of  eczema  to  produce  ulcers  in  certain 
regions  of  the  body  places  this  disease  within  the  category 


150  SURGICAL  THERAPEUTICS 

of  surgical  affections.  Hundreds  of  prescriptions  have  been 
suggested  for  this  sometimes  intractable  condition.  Merck's 
Archives  gives  the  following,  which  are  among  the  best. 
In  acute  eczema,  blue  mass  or  compound  cathartic  pill, 
followed  next  morning  by  an  effervescent  saline  laxative 
will  be  found  advisable.  Natural  mineral  waters  are  useful. 
When  both  iron  and  magnesium  sulphate  are  indicated 
the  following  may  be  used: 

Magnesii  sulph 64.0  (ozs.    2) 

Acidi  sulphur,  dil 16.0  (drs.    2) 

Ferri   sulph ". 0.6  (grs.  10) 

Sodii  chlor 4.0  (dr.     i) 

Tinct.  cardamom,  comp  ...  4.0  (dr.      i) 

Aquae  dest 256.0  (ozs.    8) 

Filtra.  Sig:  One  tablespoonful  before  breakfast  in  a 
tumblerful  of  cool  or  hot  water. 

In  case  of  renal  derangement  diuretics  are  indicated, 
and  in  gouty  cases,  colchicum  and  Vichy  water. 

When  both  diuretics  and  alkalies  are  indicated,  the 
following  may  be  used: 

Magnesii  sulph 16.0  (oz.        1-2) 

Magnesii  carb 4.0  (dr.    i       ) 

Tinct.   colchici 2.0  (dr.        1-2) 

Ol.  menth.  pip o.i  (min.  2       ) 

Aquae  dest 192.0  (ozs.  6       ) 

The  following  is  a  useful  lotion: 

Phenol 3.0  (grs.  45) 

Zinci  oxidi 4.0  (dr.      i ) 

Glycerini 8.0  (drs.    2) 

Aquae  calcis q.  s.  ad.  252.0  (ozs.    8) 

In  this  formula,  when  carbolid  acid  (phenol)  does  not 
act  favorably,  dilute  hydrocyanic  acid  may  be  substituted. 
Tragacanth  mucilage  may  be  used  instead  of  glycerin,  or 


ECZEMA  151 

both  may  be  omitted  and  half  the  amount  of  lime  water 
may  be  replaced  by  an  equal  quantity  of  elder-flower  water: 

Acidi  hydrocyanici  dil 4.0  (dr.    i) 

Zinci  oxidi 4.0  (dr.    i) 

Calaminae 4.0  (dr.    i ) 

Aquae  calcis 128.0  (ozs.  4) 

Aquae  sambuci 1 28.0  (ozs.  4) 

Use  as  a  lotion  three  or  four  times  a  day. 
It  must  be  borne  in  mind  that  a  disturbed  nervous 
system,  associated  with  a  chronic  intestinal  indigestion, 
will  always  be  found  back  of  the  eczematous  manifestations; 
so  arsenic  and  strychnine  are  frequently  indicated,  but 
particularly  must  attention  be  directed  to  proper  food 
selection. 

Influence  of  Diet  in  the  Treatment  of  Eczema. — 
Ravogli  says  that  next  to  the  kidneys  the  skin  must  be  con- 
sidered as  an  organ  of  elimination;  indeed  it  has  more 
eliminating  power  for  some  products  than  the  kidneys 
themselves.  The  occurrence  of  eruptions  after  the  inges- 
tion  of  certain  foods  is  not  accidental.  The  skin  is  active 
in  eliminating  substances  which  are  detrimental  to  the 
general  economy.  Individuals  subject  to  eczema  should 
subsist  upon  good,  wholesome  home  cooking.  The  food 
should  be  fresh  and  of  unquestionable  nature.  When  prod- 
ucts of  fermentation  develop  in  the  stomach  or  in  the 
intestines  it  must  be  admitted  that  there  is  a  diseased  con- 
dition of  the  functional  activity  of  these  organs.  There 
is  usually  a  catarrhal  condition  of  the  mucosa  of  the  stom- 
ach or  a  nervous  condition  which  brings  about  "dyspepsia." 
The  same  may  be  present  in  the  intestines.  The  diet  in 
such  cases  must  protect  the  parts  as  much  as  possible  and 
eliminate  non-irritating  qualities.  Food  which  leaves  the 
smallest  possible  residue  should  be  eaten.  As  a  rule 
therefore  a  coarse  diet  is  better  than  a  light  diet.  One 
should  advise  the  use  of  graham  and  rye  bread  together  with 


152  SURGICAL  THERAPEUTICS 

honey,  fruit  juices,  stewed  plums,  leguminous  plants, 
boiled  and  baked  potatoes;  plenty  of  fresh  milk,  cream, 
and  butter  are  also  adyised.  Meats,  beef,  veal,  fresh  pork, 
boiled  ham,  chicken,  with  plenty  of  vegetables  are  to  be 
given  without  fear,  as  well  as  fresh  white-fish,  trout  and  so 
forth.  Dark  meats,  venison,  corned  beef,  mackerel,  lobster, 
eel,  and  strong  cheese  are  forbidden.  Candies  and  sugar 
must  not  be  taken.  Fresh  country  air  and  natural  mineral- 
spring  waters  are  very  helpful  in  the  treatment  of  these 
cases.  The  influence  of  diet  on  the  treatment  of  eczema 
in  gouty  people  is  almost  incredible. 

Surgeon's  Eczema. — By  reason  of  much  hand  scrub- 
bing, long  continuance  of  the  hands  in  fluids  and  exposure 
to  cold  air  before  perfect  drying,  the  hands  of  busy  opera- 
tors are  apt  to  become  sore  from  a  kind  of  dry  eczema, 
especially  in  very  cold  weather.  Applications  of  vase- 
line camphor-ice  each  night  will  prevent  this;  so  also 
the  use  of  the  following: 

Phenol   5.00 

Oil  of  cade 10.00 

Lanolin    500.00 

Oil  of  rose q.  s. 

This  is  to  be  well  rubbed  in  each  night,  with  especial 
attention  to  palmar  surfaces. 

EMPYEMA 

The  treatment  of  pyothorax  may  be  summed  up  in 
two  words:  proper  drainage.  What  constitutes  proper 
drainage  is  the  only  source  of  controversy,  but  the  fol- 
lowing may  be  said  to  be  definitely  settled:  (i)  Empy- 
ema  of  childhood  may  be  successfully  treated  by  mere 
incision  under  perfect  antiseptic  precautions  in  a  large 
percentage  of  cases;  persistent  discharge  (more  than  six 
weeks)  may  necessitate  excision  of  a  small  piece  of  rib. 
(2)  In  some  instances  of  the  disease  in  adult  life  the 


ENEMA:     NUTRIENT  153 

Estlander  operation  is  sufficient;  removal  of  three  or  four 
inches  of  one  or  two  ribs.  (3)  If  the  discharge  con- 
tinues more  than  two  months  after  an  Estlander  opera- 
tion, the  more  extensive  Schede  operation  must  be  resorted 
to:  excision  of  the  entire  chest- wall,  including  the  parietal 
pleura,  over  as  much  of  the  thorax  as  the  abscess-cavity 
underlies;  that  is,  all  of  the  external  surface  of  the  abscess- 
cavity  must  be  cut  away,  leaving  nothing  but  the  pyogenic 
visceral  surface,  which  must  be  cleaned  by  rubbing  with 
gauze,  the  skin  being  then  allowed  to  fall  in  upon  the 
more  or  less  collapsed  lung.  If  this  extensive  area  be 
kept  clean  by  simply  wiping  it  carefully  every  second  or 
third  day,  healthy  granulations  will  spring  up;  and  as 
the  cavity  is  obliterated,  the  lung  will  expand  until  by 
the  time  the  wound  closes,  very  .little  depression  will 
remain  in  most  cases.  The  cavity  should  not  be  irrigated 
with  water,  hydrogen  dioxide  or  any  other  liquid,  as  a 
rule;  all  that  is  needful  is  cleaning  away  the  excess  of  pus 
without  disturbance  of  the  granulations  and  loosely  pack- 
ing with  plain  gauze  covered  by  an  abundance  of  absorb- 
ent cotton.  By  this  simple  treatment  convalescence  is 
much  more  rapid  and  the  resultant  deformity  less  marked 
than  when  the  surgeon  does  too  much  in  the  way  of  irri- 
gating, washing,  sponging  and  using  antiseptic  agents. 
Internally  the  patient  should  be  given  the  best  of  food, 
codliver  oil  or  cream  in  large  quantities,  tonics  and  stimu- 
lants; for  the  primary  lesion  usually  is  of  tuberculous 
character  and  unless  free  drainage  is  secured  and  the 
general  health  supported,  pulmonary  tuberculosis  will 
follow;  but  if  the  proper  treatment  is  carried  out,  recovery 
may  be  secured  in  a  majority  of  cases. 

ENEMA:    NUTRIENT 

After    abdominal    section    (and   some    other    serious 
operations  as  well)   rectal   feeding  becomes  a  necessity. 


154  SURGICAL  THERAPEUTICS 

An  excellent  nutrient  enema  is  made  by  dissolving  a  table- 
spoonful  of  sugar  in  a  teacupful  of  hot  water  and  boiling 
in  it,  for  a  few  minutes,  a  teaspoonful  of  starch;  add  a 
wineglassful  of  wine;  beat  up  two  eggs  in  a  tablespoon- 
ful  of  milk  and  mix  with  the  other  and  inject.  It  may 
be  repeated  every  four  to  six  hours  until  the  patient  is 
able  to  take  nourishment  by  the  mouth. 

ENURESIS  NOCTURNA 

That  "wetting  the  bed"  by  a  child  should  be  a  symp- 
tom of  nasopharyngeal  adenoids  seems  at  first  glance  to 
be  ridiculous;  but  we  cannot  but  be  convinced  of  the 
accuracy  of  the  observation  when  one  notes  the  results 
in  twenty-three  children  suffering  from  enuresis  nocturna 
who  were  found  to  have  adenoid  growths  and  removal 
was  practised.  Of  the  twenty-three  operated  upon, 
there  were  twelve  in  which  the  enuresis  (of  several  years' 
duration)  practically  ceased  immediately,  or  within  a 
short  time  after  operation,  and  did  not  return  during 
the  time  it  was  possible  to  keep  the  children  under  obser- 
vation. In  five  more,  recurrence  was  noted  only  after 
long  intervals,  or  only  after  a  cold  causing  temporary 
nasal  obstruction;  in  two  improvement  was  moderate; 
hi  one  there  was  no  return  (period  of  observation  after 
operation  only  nine  days);  while  in  only  three  removal 
of  the  adenoids  had  no  apparent  effect  upon  the  enuresis. 

Three  explanations  are  allowable  as  to  the  effect  of 
operation  hi  overcoming  the  enuresis:  One  is  the  impress 
upon  the  nervous  system  by  the  shock  of  operation;  the 
second  (and  a  far  more  plausible  one)  finds  in  the  reestab- 
lishment  of  nasal  respiration  a  removal  of  the  exciting 
cause  of  enuresis;  while  the  third  (my  own)  is  that  the 
adenoids  excite  the  sexual  centers  of  the  nasal  mucous 
membrane  and  cause  the  bladder  to  act  unwisely.  (See 
note  on  "Nasal  Dysmenorrhea.")  This  latter  relation  is  in 


EPILEPSY:     TRAUMATIC  155 

accordance  with  the  theory  of  Major,  which  presumes 
the  cause  of  the  enuresis  to  be  the  overloading  of  the 
blood  with  carbonic-acid  gas.  Gronbeck  does  not  regard 
all  cases  of  enuresis  as  due  to  adenoids;  but  says  that 
impeded  nasal  respiration  should  always  be  regarded  as 
a  possible  factor  and  that  in  children  the  most  frequent 
cause  of  such  trouble  is  nasopharyngeal  lymphoid  growths. 

EPIDIDYMITIS 

According  to  Mackinney  best  results  are  obtainable 
in  gonorrheal  epididymitis  by  the  application  of  a  sat- 
urated solution  of  magnesium  sulphate,  in  conjunction 
with  elevation  of  the  scrotum.  After  the  acute  symptoms 
are  relieved  an  ointment  composed  of  equal  parts  of  the 
ointments  of  belladonna  and  mercury,  together  with  the 
same  quantity  of  ichthyol  ointment,  lo-percent,  and 
lanolin,  should  be  employed  to  hasten  the  absorption  of 
the  exudate. 

As  a  local  application  for  epididymitis  there  is  nothing 
superior  to 

Aqueous  extract  of  opium 8.0  (drs.  2) 

Guaiacol 8.0  (drs.  2) 

Lanolin 32.0  (oz.    i) 

Half  vaseline  may  be  used  after  the  first  boxful;  it 
does  not  permit  such  rapid  absorption.  The  salve  is 
equally  soothing  and  remedial  in  orchitis. 

EPILEPSY:  TRAUMATIC 

Far  more  cases  of  epilepsy  depend  upon  trauma 
than  is  generally  supposed.  Those  in  which  depressed 
fracture  or  other  local  irritation  can  be  determined  are 
fit  subjects  for  operative  treatment;  but  the  friends  of 
the  patient  should  be  thoroughly  impressed  with  the 
idea  that  the  patient  must  be  kept  under  internal 
treatment  for  at  least  a  year  after  operation.  In  truth 


156  SURGICAL  THERAPEUTICS 

more  epilepsy  is  absolutely  curable  than  taught  in  our 
books.  But  in  assuming  treatment  of  any  case  there 
should  always  be  a  written  agreement  that  the  patient 
shall  be  under  control  at  least  two  years,  during  which 
time  one  should  treat  every  function  of  the  individual 
so  as  to  keep  his  general  health  in  the  best  possible  con- 
dition. Of  course,  institutional  treatment  is  better  in 
most  cases  than  private  treatment.  Bromides  and  elim- 
inatives  are  the  basis  of  therapy;  but  solanine  in  doses  of 
1-67  grain  four  times  a  day,  pushed  up  gradually  to  1-12 
grain,  is  earnestly  advocated.  Above  all,  the  food  must 
be  of  the  most  simple,  easily  digestible  kind,  and  never 
eaten  in  excess;  and  the  colon  must  be  kept  as  nearly 
empty  as  possible. 

EPISTAXIS 

When  nosebleed  is  persistent  the  nares  may  be  plugged 
by  tamponing  with  a  long,  narrow  strip  of  iodoform  gauze 
through  each  nostril;  or  a  string  may  be  passed  through 
from  front  to  back,  brought  out  of  the  mouth  and  attached 
to  a  roll  of  gauze  large  enough  to  plug  the  posterior  nares 
when  it  is  pulled  up  behind  the  soft  palate,  and  against 
this,  held  firmly  by  the  string,  the  gauze  tampon  may  be 
packed  tightly  upon  the  side  from  which  the  hemorrhage 
occurs.  Aconitine,  one  milligram  (1-67  grain),  and  vera- 
trine,  half  a  milligram  (1-134  grain),  may  be  given  every 
half  hour  until  the  pulse  becomes  soft.  Lemon  juice 
or  even  vinegar  may  be  injected  into  the  nostril  in  less 
serious  cases.  Injection  of  adrenalin  sometimes  arrests 
it  instantly;  and  a  2o-percent  solution  of  antipyrin  also 
acts  energetically  as  a  styptic.  Ice  to  the  back  of  the 
neck  is  a  "home  remedy"  often  very  effective. 

ERYSIPELAS 

Convalescence  from  Erysipelas. — During  conval- 
escence energetic  use  of  tonics  is  indicated.  Iron  and 


ERYSIPELAS  157 

bitters  are  each  commendable.     The  following  combina- 
tion is  good: 

Tincture  of  chloride  of  iron..  16.0  (drs.    4) 

Simple  syrup 50.0  (drs.  12) 

Whisky 192.0  (ozs.    6) 

Mix.  Direct'  One  tablespoonful  one  hour  after  each 
meal. 

Arsenic,  two  milligrams,  and  strychnine  the  same,  may 
well  be  given  at  meal  time  in  a  capsule  with  quinine. 

Facial  Erysipelas. — Early  in  an  attack  of  erysipelas 
of  the  face  it  is  a  good  plan  to  cover  the  affected  area 
with  equal  parts  of  ichthyol  and  extract  of  belladonna, 
a  piece  of  rubber  tissue  or  oiled  silk  being  placed  over 
it  to  keep  out  the  air.  A  half  centigram  (gr.  1-12)  of 
pilocarpine  may  be  given  hypodermically,  and  repeated 
by  mouth  every  two  hours  until  profuse  perspiration  is 
induced;  then  one  every  four  to  six  hours  to  keep  the  skin 
constantly  moist.  The  bowels  must  be  kept  active,  pref- 
erably by  saline  laxatives.  If  the  temperature  runs  high 
a  few  doses  of  acetanilid  (half  gram,  repeated  in  two 
hours — twice  in  twenty-four  hours)  may  be  given  early 
in  the  trouble,  but  must  be  watched  carefully  later.  Stimu- 
lants and  food  are  indicated  always.  Sulphate  of  strych- 
nine (one-fourth  centigram — 1-20  grain)  may  be  given 
every  six  hours  when  the  patient  is  weak. 

Local  Applications  in  Erysipelas, — The  erysipelatous 
area  may  be  painted  with  pure  phenol,  or  with  a  solution 
of  160  grains  of  silver  nitrate  to  the  ounce  of  water,  though 
this  sometimes  causes  a  slough,  and  then  covered  thickly 
with  a  paste  made  of  equal  parts  of  ichthyol  and  lanolin; 
rubber  tissue  should  be  placed  over  this  and  then  a  pad 
of  absorbent  cotton  held  in  place  by  a  bandage.  This 
dressing  must  be  changed  twice  a  day.  If  there  be  great 
pain  belladonna  ointment  may  be  substituted  for  the 
lanolin. 


158  SURGICAL  THERAPEUTICS 

Treatment  of  Facial  Erysipelas. — For  more  than 
a  quarter  of  a  century  Prof.  W.  F.  Waugh  has  not  had  a 
case  of  facial  erysipelas  which  did  not  promptly  yield  to 
treatment,  consisting  of  pilocarpine  in  sthenic  cases  and 
iron  in  asthenic  ones;  with  practically  no  attention  to 
local  measures  save  exclusion  of  the  air.  In  sthenic  cases 
the  pilocarpine  is  given  every  hour  until  sweating  occurs. 
When  this  takes  place  the  edges  of  the  involved  area 
begin  to  recede.  This  remedy  is  then  suspended  for  a 
day,  and  if  the  eruption  continues  the  treatment  is  resumed 
until  it  is  evident  that  the  remedy  has  perfect  control  of 
the  disease.  In  asthenic  cases  the  tincture  of  the  chloride 
of  iron,  thirty  drops,  is  given  every  four  hours,  and  nour- 
ishment is  crowded,  when  improvement  sets  in  at  once. 

ESOPHAGUS:    FOREIGN  BODY  IN 

Candler  suggests  that  apomorphine,  half  a  centigram 
(gr.  1-12)  injected  hypodermically,  will  quite  often  cause 
the  expulsion  of  the  offending  substance.  Give  enough 
apomorphine  and  the  stomach  will  empty  itself  within 
five  minutes.  As  the  drug  relaxes  muscular  tissues  gen- 
erally, it  serves  in  this  instance  a  double  purpose. 

FECAL  DISORDERS 

Fecal  Fistulas. — In  spite  of  every  precaution  dur- 
ing operation  a  fecal  fistula  will  form  now  and  then,  espe- 
cially in  dealing  with  periappendical  abscess.  Fortunately 
far  more  than  a  majority  of  the  cases  heal  spontaneously 
in  a  very  few  days  to  a  year,  a  year  being  the  practical 
limit  in  which  nature  may  be  expected  to  cure  the  con- 
dition. Those  sinuses  running  through  the  vaginal  canal 
are  usually  a  better  prognosis  than  the  abdominal  wall. 
When  secondary  section  is  made  to  close  the  opening 
in  the  gut  a  large  proportion  of  the  cases  die  from  exhaus- 
tion or  complicated  conditions;  the  operation  itself  cures 
about  50  percent.  Therefore  it  is  best  to  exhaust  medi- 


FEET:     DISORDERS  OF  159 

cal  and  local  treatment  before  any  operation  is  tried. 
The  diet  should  be  non-fermenting  and  easily  digestible, 
the  patient  kept  in  bed  for  a  long  time  and  the  parts  kept 
surgically  clean  as  far  as  possible,  and  every  effort  made 
to  close  the  wound  at  the  intestinal  opening.  After  the 
sinus  is  gotten  as  clean  as  it  may  be  from  packing  and 
cleansing,  the  bowel  should  be  thoroughly  cleared  out 
and  then  peristalsis  checked  by  the  free  use  of  morphine, 
allowing  if  possible  a  rest  of  one  week  with  concentrated 
food.  The  moving  of  the  bowels  is  then  done  by  enemas. 
The  surgical  treatment  consists  in  removal  of  the  sinus 
and  a  wedge-shaped  piece  of  gut. 

For  Fecal  Impaction. — In  cases  of  fecal  impaction 
try  rectal  injection  of  a  pint  of  kerosene.  It  often  "works" 
admirably. 

FEET:    DISORDERS  OF 

Flat-Foot» — These  cases  are  separable  into  three 
classes:  (i)  The  flabby,  easily  moved  foot  which,  on 
weight-bearing,  becomes  pronouncedly  flat,  due  to  a 
laxity  of  the  muscles  and  ligaments.  The  condition  is 
associated  with  vasomotor  disturbances  and  varicose 
veins,  and  is  due  possibly  to  altered  circulatory  condi- 
tions. If  a  pad  is  used  to  correct  the  condition,  tonics 
and  massage  are  also  indicated.  Instead  of  the  pad  it 
is  better  to  raise  the  inner  side  of  the  sole  and  heel  and 
by  thus  causing  inversion  and  adduction,  bring  about  a 
physiological  raising  of  the  arch.  (2)  The  spasmodic 
form,  resulting  from  a  persistence  of  the  above,  or  due 
to  injury  such  as  a  sprain  or  Pott's  fracture,  rheumatic 
fever  or  gonorrhea.  The  spasm  must  be  overcome  by 
rest  or  manipulation,  putting  the  foot  in  an  overcorrected 
position  in  plaster.  If  need  be,  tenotomize  the  extensor 
communis  digitorum  and  peronei  muscles.  (3)  Rigid  flat 
feet  with  great  alterations  in  the  relations  of  the  bones 


160  SURGICAL  THERAPEUTICS 

and  seeming  ankylosis.     Here    operation    is   called   for: 
Exsection   of   the   astragalo-scaphoid  joint. 

Sweating  Feet, — The  following  formula  is  an  excel- 
lent one  for  sweating  of  the  feet: 

Potassium  permanganate 13  parts 

Alum i  part 

Talc 50  parts 

Zinc  oxide 18  parts 

Calcium  hydrate 18  parts 

Another  formula  highly  recommended  is: 

Salicylic  acid 2  parts 

Zinc  stearate i  part 

Talc 40  parts 

Compound  tincture  of  vanilla q.  s. 

The  last-named  ingredient  is  simply  to  cover  the 
odor. 

Swollen  Feet. — Swelling  of  the  feet  may  be  found 
in  (i)  dropsy,  especially  from  a  weak  heart,  (2)  those  who 
take  but  little  exercise  but  are  rheumatic  or  gouty,  par- 
ticularly found  in  elderly  people,  and  (3)  those  who  are 
compelled  to  stand  or  walk  too  much,  notably  if  bad 
shoes  are  worn.  In  every  one  of  these,  however,  small 
doses  of  arsenic  (a  milligram  or  two  three  times  a  day) 
will  do  good;  and  in  the  first  and  last  varieties  strychnine 
may  be  added  in  the  same  dose  but  must  not  be  con- 
tinued longer  than  three  weeks.  In  every  case  careful 
examination  of  the  respiratory,  circulatory  and  renal 
system  must  be  made  before  deciding  the  condition  to  be 
trivial 

Tender  Feet. — From  too  tight  shoes,  from  standing 
too  long,  from  abrasions  of  the  skin,  from  too  thin  soles, 
etc.,  the  feet  often  become  tender  and  quite  painful.  Bath- 
ing in  very  hot  water  every  night  is  comforting.  If  the 


FINGER3:     CONTRACTURES  O  161 

skin   continues   tender,  the  feet  should  oe  rubbed  morn- 
ing and  evening  in 

Salicylic  acid 5.0  (drs.  i  1-2) 

Borax 10.0  (drs.  3        ) 

Glycerin    128.0  (ozs.  4       ) 

Water    128.0  (ozs.  4       ) 

Sometimes  the  arch  of  the  foot  is  weak  and  in  need 
of  a  light  steel  spring  in  the  bottom  of  the  shoe.  The 
use  of  rubber  heels  relieves  many  cases  of  footache. 

FELON:    TO  ABORT 

Over  a  forming  whitlow  apply  absorbent  cotton  sat- 
urated with  alcohol,  and  cover  with  a  piece  of  rubber 
tissue  (or  even  a  large  finger-cot)  in  such  a  way  as  to 
exclude  the  air.  In  from  sixty  to  seventy-two  hours 
relief  will  be  complete,  and  a  cure  effected  in  a  majority 
of  cases — practically  all  if  seen  early. 

FEVERS:    SURGICAL 

Aconitine  is  a  valuable  drug  in  controlling  the  fever 
which  naturally  follows  infection  of  a  wound — such  as 
a  crushed  foot  or  an  abscess  or  boil.  It  may  be  given 
in  doses  of  one-half  milligram  (gr.  1-134)  every  half  hour 
until  the  temperature  falls.  If  dispensed  in  granule  form 
the  patient  must  be  instructed  to  swallow  it  quickly,  throw- 
ing it  well  back  into  the  throat,  or  disagreeable  and  per- 
sistent numbness  of  the  tongue  will  be  produced;  or  it 
may  be  given  dissolved  in  at  least  an  ounce  of  water.  A 
small  capsule  may  be  used  if  preferred.  This  dosage  is  for 
the  "amorphous"  aconitine.  It  must  be  remembered 
that  there  is  a  "crystalline  aconitine"  upon  the  markets — 
several  times  as  strong — the  dose  of  which  is  1-500  grain. 

FINGERS:    CONTRACTURES  OF 

Sometimes  contracture  of  the  fingers  following  the 
treatment  of  a  cellulitis  of  the  hand  and  forearm  may 


162  SURGICAL  THERAPEUTICS 

be  due,  not  to  the  cellulitis  itself  nor  to  the  incisions  made 
to  relieve  it,  but  to  fibrosis  and  shortening  of  the  flexors 
in  the  forearm,  the  result  of  too  tight  bandaging  or  strap- 
ping. Such  a  condition — Volkmann's  ischemic  muscle 
contracture — must,  therefore,  be  distinguished  from  the 
stiff,  flexed  fingers  produced  by  cellulitis.  Passive  motions 
and  massage  are  helpful  in  both  conditions,  but  in  the 
former  shortening  of  the  radius  and  ulna  is  necessary  to 
accommodate  the  contractured  muscles. 

FISTULA:   TREATMENT  AFTER  OPERATION 

At  the  completion  of  operation  for  fistula  of  the  anus 
a  hard-rubber  tube  is  introduced  well  above  the  cut  sphinc- 
ter and  gauze  tamponed  around  it  firmly.  This  permits 
the  escape  of  gas  while  the  barrier  of  beginning  granulation 
starts  upon  the  raw  surface.  That  granulation  may  be- 
come fairly  well  established  before  irritation  by  the  passing 
feces  is  permitted  it  is  best  to  keep  the  bowels  from  moving 
for  six  days  if  possible,  a  liquid  diet  being  advised.  If  the 
packing  is  saturated  with  the  wound-discharge  before  this 
time  it  may  be  removed  and  fresh  gauze  inserted;  but  as 
this  is  very  painful  it  is  better  to  leave  the  original  packing 
several  days  even  if  it  does  become  very  foul  of  odor.  When 
the  gauze  is  removed  a  high  enema  of  olive  oil,  or  an  ox- 
gall  enema  may  be  given.  Later  a  saline  laxative  is  to  be 
ordered.  After  the  bowels  have  moved  the  wound  should 
be  cleaned  by  gentle  washing,  the  two  raw  surfaces  being 
carefully  separated,  iodoform  dusted  in  freely  and  a  strip 
of  iodoform  gauze  carried  well  into  the  rectum  and  packed 
loosely  into  the  cut;  with  a  pad  of  absorbent  cotton  over 
all,  supported  by  a  T-bandage.  If  possible  the  dressing 
should  be  made  twice  daily  for  some  days;  later  once  daily; 
and  as  the  discharge  lessens,  every  second  day,  though  the 
patient  is  instructed  to  clean  it  as  well  as  possible  after 
each  bowel-inovement.  Should  granulation  be  too  slow, 


FRACTURES  163 

dressing  with  balsam  of  Peru  daily  will  soon  stimulate  the 
surfaces  sufficiently  to  insure  early  healing.  The  patient 
should,  when  circumstances  permit,  lie  in  bed  two  weeks; 
but  most  will  insist  upon  being  at  work  in  ten  days — which 
does  not  greatly  retard  healing  if  operation  has  been  done 
properly.  Most  careful  attention  must  be  paid  to  building 
up  the  general  health  of  the  patient  during  convalescence. 
Temporary  loss  of  sphincteric  control  need  not  occasion 
anxiety. 

FRACTURES 

Colles's  Fracture, — The  inflexible  rule  in  Colles's 
fracture  should  be  to  refuse  treatment  unless  the  patient 
will  permit  reduction  in  complete  surgical  narcosis.  If 
dressings  are  applied  without  anesthesia  great  deformity 
is  almost  sure  to  follow.  But  if  all  muscles  be  relaxed 
it  is  easy  to  exert  sufficient  force  to  overcome  the  defor- 
mity at  once,  when  if  pains  be  taken  to  maintain  the  nor- 
mal position  of  the  ulna  by  a  sufficiently  hard  and  prop- 
erly applied  pad,  placed  on  the  palmar  side  of  the  end 
of  the  ulna,  an  excellent  result  can  be  predicted.  If,  in 
addition,  early  massage  and  movements  of  the  fingers, 
both  active  and  passive,  be  employed,  the  very  best 
results  can  be  obtained  in  the  great  majority  of  cases. 
When  the  desired  method  cannot  be  adopted  the  wrist 
may  be  put  as  nearly  straight  as  possible  and  several 
straps  of  adhesive  plaster  wrapped  around  wrist  and 
forearm. 

Fracture  of  the  Acromion. — Raise  shoulder  by 
supporting  elbow  in  sling;  place  pad  in  axilla;  bind  arm 
to  side  by  broad  bandage  around  body.  Ligamentous 
union  may  be  expected.  Liberate  in  three  weeks. 

Fracture  of  the  Fingers. — Pull  the  broken  finger 
until  it  is  straight  and  apply  a  small  splint  extending 
well  up  into  the  palm  of  the  hand  and  bandage  rather 


164  SURGICAL  THERAPEUTICS 

tightly.  Tighten  the  bandage  in  a  day  or  two  when 
swelling  subsides  and  leave  splint  on  for  ten  days.  When 
the  fracture  occurs  into  a  joint,  passive  motion  must 
be  instituted  as  soon  as  the  splint  can  be  removed. 

Fracture  of  the  Forearm. — When  both  bones  of  the 
forearm  are  broken  the  fragments  should  be  replaced  under 
chloroform.  A  thin,  hard  splint,  extending  well  down  into 
the  palm  (and  also  well  above  the  elbow  if  the  break  is 
within  two  inches  of  that  joint),  should  be  placed  on  the 
front  and  a  smaller  one  on  the  back,  held  by  a  two-inch 
bandage  snugly  applied.  The  splints  should  be  well 
padded.  Bandages  must  be  tightened  on  the  third  or 
fourth  day,  great  care  being  taken  that  the  fragments  are 
not  displaced.  In  children  plaster  of  paris  may  be  applied 
after  the  swelling  is  gone.  The  splint  must  be  worn  three 
weeks.  Advocation  of  early  passive  motion  is  to  be 
condemned. 

Fractures  of  the  Head  of  Radius. — The  x-ray  has 
shown  that  fractures  of  the  head  of  the  radius  are  common 
instead  of  rare  as  taught  heretofore.  It  shows  that  in  the 
uncomplicated  variety  (probably  the  most  frequent),  a 
vertical  line  of  fracture  separates  the  anterior  third  or  half 
of  the  head.  Thomas  says:  In  a  fall  on  the  hand  with 
the  elbow  extended,  only  this  portion  of  the  head  is  in  con- 
tact with  the  capitellum  of  the  humerus,  so  that  the  down- 
ward impact  breaks  it  off;  the  resistance  of  the  intact  coro- 
noid  process  prevents  separation  of  the  fragments  and 
consequent  rupture  of  the  orbicular  ligament;  the  lines  of 
fracture  on  the  upper  surface  of  the  head  tend  to  radiate 
from  the  periphery  towards  the  center,  so  that  when  less 
than  a  half  of  the  head  is  detached  the  small  fragment  is 
angular  in  shape;  it  fits  closely  into  a  corresponding  depres- 
sion in  the  remaining  portion  of  the  head,  and  is  held  there 
by  the  untorn  orbicular  ligament.  As  a  result,  the  head 
will  move  as  a  whole  within  the  ligament,  movement  of 


FRACTURES  165 

one  fragment  on  the  other  being  impossible.  Sometimes 
the  line  of  fracture  is  straight,  especially  when  the  detach- 
ment includes  half  of  the  head,  and  in  these  cases  crepitus 
will  be  possible.  Absence  of  crepitus  in  the  presence  of 
positive  fracture  is  peculiar,  but  the  localized  and  severe 
pain  and  tenderness,  and  the  limitation  of  motion  in  the 
elbow,  are  sufficiently  characteristic  to  establish  the  diag- 
nosis in  most  cases,  much  more  so  than  in  the  average  case 
of  fractured  rib.  The  fact  that  this  fracture  is  always 
intracapsular  makes  it  important  from  the  standpoint 
of  prognosis,  although  the  close  splinting  of  the  fragments 
by  the  untorn  orbicular  ligament  favors  a  good  result  in 
most  cases.  It  is  probable  that  most  of  the  obscure 
"sprains"  of  the  elbow,  followed  by  more  or  less  ankylosis, 
are  in  reality  fractures  of  the  head  of  the  radius.  Fixation 
of  joint  for  three  weeks  is  all  the  treatment  usually  needed. 
It  will  rarely  be  necessary  to  excise  the  head  of  the  radius, 
as  is  done  by  Stimson  in  most  of  his  cases,  or  to  excise 
the  detached  fragment,  as  is  done  by  Cheyne. 

Fracture  of  the  Humerus. — Reduce  fracture  as  well 
as  possible  and  put  in  wooden  splints  until  swelling  is 
gone.  On  the  fourth  to  the  sixth  day  chloroform  the  patient, 
remove  the  splint,  put  the  fractured  ends  in  exact  apposition 
and  apply  a  plaster-of-paris  splint  over  a  layer  of  cotton 
batting,  including  shoulder  and  elbow  bent  at  nearly  right 
angle.  Have  the  forearm  carried  in  a  sling.  Remove  the 
plaster  in  four  weeks  and  use  passive  motion. 

If  the  break  is  into  the  elbow,  passive  motion  should 
be  begun  at  the  third  week,  the  wooden  splint  being  reap- 
plied  after  each  treatment.  A  good  joint  can  usually  be 
secured  in  children,  if  motion  be  made  daily  after  the  end 
of  the  third  week. 

Fracture  of  the  Leg, — Chloroform  the  patient  and 
correct  the  deformity.  Put  in  splints  from  the  sole  of  the 
foot  to  above  the  knee — one  on  each  side  of  the  leg,  well 


166  SURGICAL  THERAPEUTICS 

padded — and  bandage  so  as  to  immobilize  the  ankle  and 
knee.  In  four  days  remove  the  splints,  with  the  help  of 
another  doctor  who  will  prevent  displacement  of  the  frag- 
ments; wrap  the  leg  in  cotton-batting  and  apply  four  3- 
inch  plaster-of-paris  bandages,  including  the  ankle  and 
knee.  Let  the  patient  out  on  crutches  at  the  end  of  one 
week;  no  weight  is  to  be  borne  on  foot.  Remove  the 
plaster  at  the  end  of  three  weeks — four  weeks  in  the  case 
of  debilitated  patients — and  permit  the  patient  to  walk 
with  a  cane. 

Fracture  of  the  Olecranon.— -In  fracture  of  the 
olecranon  Murphy  advises  subcutaneous  wiring.  It  may 
be  done  without  opening  the  joint  and  without  any  danger 
of  infection  if  one  is  very  careful  as  to  aseptic  details. 

Fracture  of  the  Patella. — Incision  over  the  frac- 
ture, withdrawal  of  the  soft  tissues  from  between  the 
fragments  and  suturing  with  twenty-day  chromic  gut,  con- 
stitute the  essential  features  of  the  most  approved  treat- 
ment of  fracture  of  the  patella. 

The  mortality  of  cases  properly  operated  upon  is  no 
higher  than  that  of  those  not  cut.  In  a  case  not  operated 
upon,  the  patient  generally  does  not  get  full  use  of  the 
limb,  cannot  kneel  well  and  has  difficulty  in  going  up-stairs 
or  up-hill.  Only  those  cases  in  which  there  is  no  separa- 
tion of  the  fragments  give  ideal  results  from  non-opera- 
tive treatment.  In  cases  treated  by  aseptic  suture  there 
is  generally  complete  return  of  function,  and  these  only 
require  half  as  long  as  the  average  for  union  to  occur. 
All  cases  in  which  the  fragments  are  widely  separated 
should  be  operated  on  at  once.  Where  the  fragments 
can  be  brought  into  perfect  apposition  easily  the  circular 
subcutaneous  suture  around  the  patella  is  perhaps  satis- 
factory, but  generally  the  bone  should  be  exposed  and 
united  by  silver  wire  or  No.  4  chromic  gut  passed  through 
holes  bored  from  the  anterior  surface  near  the  break  and 


FRACTURES  167 

coming  out  on  the  back  part  of  the  fractured  surface, 
so  that  the  joint  proper  is  not  entered.  The  ligaments 
are  sewed  with  plain  catgut.  To  get  -perfect  function 
it  is  necessary  to  begin  use  of  the  joint  early  and  to  force 
exercise  in  spite  of  pain  and  stiffness.  Massage  and 
passive  motion  must  be  begun  eight  or  ten  days  after 
operation,  and  walking  in  three  weeks. 

Fracture  of  the  Thigh. — Dress  the  fracture  by  put- 
ting the  thigh  between  sand-bags  or  in  a  splint  box  lined 
with  pillows  until  the  worst  of  the  swelling  has  disappeared. 
On  the  fourth  or  fifth  day  anesthetize  the  patient,  reduce 
the  fracture  and  apply  a  long  splint  from  below  the  foot 
to  near  the  axilla,  and  a  shorter  one  from  the  perineum 
to  beyond  the  foot — both  being  well  padded.  Bandage 
tightly,  including  the  foot  and  lower  part  of  the  abdomen 
and  hip.  Apply  a  weight  of  from  ten  to  sixteen  pounds, 
suspended  from  the  foot  over  a  pulley  at  the  end  of  the  bed, 
using  weight  enough  to  counteract  the  tendency  to  short- 
ening. Keep  the  patient  quiet  for  six  weeks.  From  one 
to  two  inches  shortening  may  be  expected,  but  if  the  pa- 
tient be  kept  quiet  and  the  weight  be  well  borne  there  may 
be  practically  none. 

Fracture  of  the  Ulna. — This  is  produced  by  a  direct 
blow,  or  by  falling  with  the  arm  across  a  sharp  edge  of 
board,  stone,  etc.  Often  more  attention  to  the  injured 
soft  parts  is  required  than  to  the  fracture  itself.  A  firm 
piece  of  pasteboard  suffices  for  a  splint.  Fixation  for 
two  weeks  is  required.  Fractures  of  the  coronoid  process 
of  the  ulna  are  not  very  common.  They  are  recognizable 
and  are  not  especially  hard  to  manage.  Fixation  of  the 
elbow-joint  at  or  beyond  a  right  angle  by  means  of  a 
plaster-of-paris  bandage  over  a  lightly  padded  gauze  or 
flannel  bandage  gives  a  good  result  after  three  weeks' 
immobilization.  But  when  left  unreduced  for  weeks,  re- 
section of  joint  has  to  be  performed. 


168  SURGICAL  THERAPEUTICS 

Operative  Treatment  of  Fractures. — Some  cases 
of  even  simple  fracture  are  better  treated  by  operation. 
Kelley,  of  Philadelphia,  thinks  the  advantages  are:  (i) 
Relief  of  pain  from  movement  of  fractured  ends  and  from 
tension  due  to  extra vasated  blood.  (2)  The  possibility 
of  accurately  approximating  and  retaining  in  position  the 
fractured  portions  of  bones.  (3)  Prevention  of  shortening 
and  deformity.  (4)  The  possibility  of  removing  clots 
and  repairing  neighboring  structures.  (5)  Excessive  callus 
formation  is  prevented,  and  in  fractures  involving  joints, 
subsequent  limitation  of  motion  and  deformity  is  also 
prevented.  (6)  Pressure  on  adjoining  structures  is  re- 
moved. (7)  Associated  dislocations  may  be  properly 
reduced.  (8)  The  period  of  disability  is  considerably 
lessened.  (9)  The  skeletal  mechanics  of  the  patient  are 
left  as  before  the  fracture.  These  advantages,  he  thinks, 
vastly  outweigh  the  possible  dangers  of  infection  or  necrosis 
of  the  fractured  ends,  and  of  an  external  scar.  When 
conservative  methods  fail  to  insure  perfect  approximation 
and  retention  and  when  the  preservation  of  the  skeletal 
mechanism  is  important,  especially  in  laborers,  there  should 
be  no  hesitancy  in  converting  a  closed  fracture  into  an 
open  one.  Absorbable  sutures  are  to  be  preferred  for 
uniting  the  bones,  and  as  all  methods  require  some  sort  of 
external  retentive  apparatus,  it  would  seem  that  the  ideal 
form  of  internal  fixation  is  by  the  heavy  (No.  3)  chromi- 
cized  catgut.  The  operative  treatment  of  open  fractures 
and  of  separated  epiphyses  and  fractures  associated  with 
locations  thus  comes  under  the  department  of  operative 
surgery. 

Swbperiosteal  Fracture. — Severe  localized  pain  after 
traumatism,  especially  in  children,  may  be  due  to  sub- 
periosteal  fracture,  notably  in  injuries  to  the  head  of  the 
humerus  or  the  femur.  Extreme  localized  tenderness  is 
the  characteristic  symptom.  An  abnormal  mobility  and 


GALLSTONES  169 

marked  deformity  are  absent,  and  crepitus  may  not  be 
e  icited.  The  break  is  usually  almost  transverse.  It  is 
to  be  treated  by  suturing  with  chromic  catgut  through 
drill-holes,  in  case  the  existence  of  the  fracture  is  recog- 
nized only  late.  Of  course  if  it  is  known  early  that  the 
fracture  is  present,  perfect  immobilization  will  give  satis- 
factory results. 

GALLIC  ACID  OINTMENT 

Practitioners  of  the  last  century  were  very  fond  of  gallic 
acid  on  account  of  its  astringent  properties.  Now  it  is 
rarely  used  except  in  the  form  of  the  unguentum  acidi 
gallici  of  the  United  States  Pharmacopeia.  This  is  pre- 
scribed for  psoriasis  and  as  an  application  to  old  sores  and 
ulcers  which  are  discharging  too  freely. 

GALLSTONES 

Thousands  of  patients  suffer  from  gallstones  and  don't 
know  it;  almost  as  many  thousands  of  doctors  continue 
pouring  pepsin  and  hydrochloric  acid  into  stomachs  sup- 
posed to  be  the  source  of  "indigestion"  or  "dyspepsia" 
instead  of  examining  carefully  and  ascertaining  the  true 
cause  of  suffering.  A  test  breakfast  and  analysis  of  the 
stomach-contents  can  be  made  by  any  recent  graduate 
(and  many  an  older  one  as  well) — but  it  is  often  regarded 
as  "too  much  trouble."  Nothing  is  too  much  trouble 
which  will  relieve  a  long-suffering  "chronic."  If  more 
time  were  spent  in  careful  examination  of  obscure  cases 
and  less  in  efforts  to  get  more  patients  from  competitors 
the  world  would  be  better  off.  The  ambition  of  too  many  a 
practiser  of  medicine  is  to  reach  that  frightful  stage  at  which 
he  can  exclaim:  "I  am  too  busy  to  read  medical  books 
and  journals."  God  pity  the  patient  of  such!  In  a  very 
large  proportion  of  cases  unsuspected  gallstones  and  chole- 
cystitis will  be  found  to  be  the  cause  of  the  indigestion  and 
pain;  removal  will  effect  a  cure. 


170  SURGICAL  THERAPEUTICS 

Avoiding  Secondary  Operations  for  Gallstones. — 
It  is  a  well-known  fact  that  quite  a  large  number  of 
patients  operated  on  for  gallstones  have  to  submit  to 
a  second  operation — for  stones  accidentally  left  behind, 
or  for  those  which  form  after  the  cholecystostomy.  Con- 
cerning the  latter  Richardson  has  shown  that  after 
operations  for  gallstones,  in  about  15  percent  of  all  cases 
there  is  a  new  gallstone  formation  necessitating  a  sec- 
ond operation.  This  usually  can  be  avoided  by  increas- 
ing the  amount  of  bile-salts  by  their  administration  by 
the  mouth.  Operation  for  gallstones  is  unfortunately 
imperative  where  there  is  occlusion  of  the  duct,  but  after 
operation,  in  order  to  prevent  a  reformation  of  stone, 
care  should  be  taken  to  increase  the  amount  of  bile-salts 
to  hold  the  cholesterin  and  bilirubin  in  solution.  It  is 
claimed  that  not  only  here  but  also  in  hepatic  colic,  if 
sodium  glycocholate  is  steadily  and  regularly  adminis- 
tered, no  more  stones  will  be  formed  and  those  remaining 
in  the  gall-bladder  will  be  gradually  dissolved.  The 
"bile in"  of  Abbott  should  be  very  useful  in  this  connec- 
tion, combining  as  it  does  all  the  important  bile  salts. 
During  the  process  of  solution  they  become  soft  and  fri- 
able so  that  they  can  easily  be  crushed  between  the  fin- 
gers. In  chlorosis  and  anemia  and  in  those  diseases  in 
which  there  is  destruction  of  hemoglobin,  the  elimination 
of  the  excessive  bilirubin  formed  is  accelerated  by  an 
increased  flow  of  bile,  and  as  the  anemias  are  largely 
the  result  of  malnutrition,  stimulation  of  the  liver  is  of 
great  therapeutic  value. 

•  Fever  with  Gallstones. — Gallstone  colic,  however 
severe,  gives  rise  to  practically  no  fever  unless  infection  of 
the  gall-bladder  has  occurred  by  the  colon  bacillus  or  one 
of  the  common  pus-producing  cocci;  in  case  high  fever 
accompanies  the  attack,  operation  is  imperative.  Long  says : 
Fever  accompanying  gallstones  depends  always  upon  infec- 


GALLSTONES  171 

tion  of  the  gall-bladder  or  ducts  and  varies  from  normal 
to  io5°F.  The  peculiarity  of  gallstone  fever  is  the  sharp 
rise  of  temperature  which  lasts  only  a  few  hours  and  drops 
suddenly  back  to  normal.  It  is  often  spoken  of  as  "a 
steeple  temperature."  It  is  not  at  all  infrequent  for  a 
patient  to  have  at  irregular  intervals  a  chill,  accompanied 
by  a  terrific  colic,  and  followed  by  a  sudden  rise  of  tem- 
perature to  io5°F.;  a  dose  of  morphine  will  relieve  the 
pain  and  in  a  few  hours  the  temperature  will  be  normal. 
It  will  be  found  at  operation  that  there  is  a  suppurating 
cholangitis  with  more  or  less  stones  in  the  gall-bladder 
and  one  in  the  common  duct. 

Gastric  Pain  vs.  Biliary  Colic. — That  the  gas- 
tric crises  of  an  unrecognized  locomotor  ataxia  may  be 
mistaken  for  gallstone  colic  has  not  been  made  sufficiently 
clear;  nor  has  sufficient  emphasis  been  laid  upon  the 
proneness  of  "morphine  fiends"  to  simulate  gallstone 
colic  in  order  to  get  a  hypodermic  injection  while  among 
strangers  where  the  usual  "dope"  cannot  be  obtained. 
Patients  who  present  themselves  apparently  in  great  pain 
and  requesting  immediate  relief,  should  always  be  looked 
upon  with  suspicion.  Thoroughness  in  examination  and 
careful  inquiry  into  personal  and  family  history  will 
unquestionably  reveal  many  cases  of  malingering  as  well 
as  clear  up  the  diagnosis  of  apparently  complicated  cases. 
The  possibility  of  apparent  gallstone  colic  being  gastric 
crisis  of  ataxia,  should  be  borne  in  mind  when  strange 
patients  request  treatment.  It  must  be  remembered  also 
that  gastric  crises  of  ataxia  may  simulate  acute  gastric 
lesions,  appearing  like  gastric  ulcer.  One  can  only  then 
arrive  at  a  right  conclusion  in  non-gastric  diseases  and 
troubles  other  than  biliary  ones  with  gastric  symptoms, 
after  a  thorough  examination  of  the  patient's  whole  body 
and  a  most  careful  study  of  all  the  secretions  and 
excretions. 


172  SURGICAL  THERAPEUTICS 

Non-Surgical  Cure  of  Gallstones. — The  statement 
is  often  made  that  gallstones  may  be  "cured"  by  copious 
draughts  of  olive  oil,  by  free  use  of  bilein,  etc.  The  truth 
of  the  matter  is  that  gallstones  of  themselves  are  of  little 
importance — a  large  proportion  of  men  and  women  past 
50  years  would  be  found  to  have  gallstones  if  the  gall- 
bladder were  opened;  it  is  only  when  an  autoinfection  of 
the  mucous  membrane  occurs  that  trouble  arises. 

The  infection  may  take  the  form  of  (i)  an  acute  chole- 
cystitis, without  occlusion  of  the  cystic  duct,  (2)  acute  inflam- 
mation of  the  gall-bladder  with  stoppage  of  the  outflow — 
abscess  of  the  gall-bladder,  (3)  milder  infection,  as  from 
the  bacillus  coli  communis,  with  or  without  cessation  of 
drainage;  all  associated  with  a  catarrhal  condition  of  the 
intestines.  These  facts  explain  the  apparent  efficacy  of 
many  of  the  vaunted  gallstone  remedies.  Most  contain 
more  or  less  drastic  purgatives,  and  they  give  unmistakable 
relief,  although  they  have  the  drawbacks  of  all  purgatives 
in  catarrh  of  the  intestines;  aggravating  the  condition  after 
a  time.  The  most  promising  field  for  internal  treatment 
is  chronic  choledochitis  without  repeated  chills  and  remit- 
tent fever,  but  it  requires  the  greatest  patience.  A  cure 
is  seldom  realized  in  less  than  four  or  five  months,  but  it 
is  possible  to  avoid  an  operation  by  careful  dietetic  and 
therapeutic  management  during  all  of  this  time.  If  the 
patient  is  under  constant  medical  supervision,  the  develop- 
ment of  serious  complications  need  scarcely  be  feared. 

The  main  point  in  internal  treatment  is  repose,  and 
this  n»ust  be  absolute  until  the  last  trace  of  the  cholecystitis 
has  completely  retrogressed.  This  may  occur  sometimes 
in  four  or  five  weeks,  in  other  cases  not  until  eight  or 
ten  weeks  or  still  longer.  After  all  traces  of  swelling  of 
the  gall-bladder  and  of  the  slightest  tenderness  have  van- 
ished, the  patient  must  be  made  to  take  plenty  of  out- 
door exercise,  abstain  from  too  much  fat,  sugar  and  starch, 


GANGLION:     CURE  OF  173 

and  keep  the  bowels  thoroughly  active  by  saline  laxative. 
Finally,  if  repeated  attacks  of  gallstone  colic  become 
troublesome,  or  if  jaundice  become  prominent,  operative 
treatment  must  be  insisted  upon.  The  succinate  of 
sodium  in  doses  of  5  grains  four  times  daily  has  proven 
actually  curative  in  a  very  large  percentage  of  cases, 
according  to  the  experience  of  Prof.  W.  F.  Waugh,  who 
has  used  this  remedy  very  extensively.  It  certainly  de- 
serves a  trial. 

Pain  of  Gallstones. — Certain  patients  subject  to 
gallstone  colic  are  relieved  by  the  use  of  gelsemium  taken 
at  the  very  onset  of  the  attack.  The  method  of  admin- 
istration is  this:  At  the  first  intimation  of  an  on-coming 
paroxysm  five  drops  of  the  tincture  of  gelsemium  are 
taken,  followed  in  fifteen  minutes  by  a  second  dose.  Fif- 
teen minutes  later  a  teaspoonful  of  sodium  bicarbonate 
is  taken  in  a  tumblerful  of  very  hot  water;  and  in  another 
quarter  hour  a  third  dose  of  gelsemium  is  taken.  If  re- 
lief is  to  be  afforded  by  this  plan  no  more  will  be  needed; 
in  rare  instances  the  first  dose  alone  checks  the  spasmodic 
contraction  which  gives  rise  to  the  attack. 

Sodium  Oleate  for  Gallstones. — A  preparation  now 
widely  used  for  jaundice  is  oleate  of  sodium.  It  is  used 
principally  for  catarrhal  jaundice  but  is  also  capable 
of  improving  jaundice  due  to  obstruction  by  gallstones, 
if  it  be  given  just  after  the  attack  of  colic  has  subsided. 
It  is  said  to  reduce  the  frequency  of  attacks  in  those  sub- 
ject to  frequent  but  not  very  severe  spells. 

GANGLION:    CURE  OF 

Sometimes  patients  will  not  submit  to  operations  for 
ganglion.  What  is  the  best  non-operative  treatment? 
Gates  says  that  the  best  treatment  is  injection  of  campho- 
phenol.  He  has  never  failed  to  effect  a  cure  by  this  agent. 
It  is  prepared  by  mixing  equal  parts  of  camphor  "gum" 


174  SURGICAL  THERAPEUTICS 

and  crystalline  carbolic  acid.  The  result  is  a  pure  white, 
slightly  oily  fluid,  with  the  odor  of  camphor.  It  is  non- 
toxic,  having  all  the  good  but  none  of  the  bad  properties 
of  carbolic  acid.  To  use  it,  the  region  of  the  ganglion 
should  be  prepared  as  for  an  operation.  The  preparation 
of  campho-phenol  in  quantity  of  15  or  20  drops  should  be 
injected  directly  into  the  ganglion  by  means  of  a  hypo- 
dermic syringe,  the  needle  of  which  has  just  been  boiled. 
There  is  some  reactionary  swelling,  but  this  soon 
subsides,  and  Gates  claims  that  a  complete  cure  is 
always  obtainable  by  one  injection.  The  limb  should  be 
kept  at  rest  on  a  splint,  or  the  patient  should  remain 
in  bed  a  few  days. 

GANGRENE 

Amputation  for  Diabetic  Gangrene. — Most  surgical 
writers  condemn  any  surgical  measures  in  diabetic  gangrene, 
following  Treves  who  said:  "Diabetic  gangrene  is  not 
within  the  scope  of  surgery;  an  amputation  in  such  cases 
is  almost  invariably  fatal. "  But — death  is  certain  without 
it;  so,  if  the  case  be  seen  early,  before  much  of  the  foot  is 
affected,  and  the  patient  will  consent,  amputation  at  the 
middle  of  the  thigh  should  be  made.  Under  modern 
methods  there  is  no  more  shock  with  this  amputation  than 
with  one  lower  on  the  leg;  hence  the  rule  should  be:  Very 
high  amputation,  or  none. 

Carbolic  Acid  Gangrene. — Many  cases  of  serious 
gangrene  have  followed  the  injudicious  use  of  phenol, 
particularly  when  wet  phenolized  dressings  have  been  cov- 
ered with  rubber  tissue  or  oiled  silk,  most  often,  too,  when 
the  original  injury  or  sepsis  is  trivial  in  degree.  The  ap- 
pearance of  the  gangrenous  part  in  such  cases  is  character- 
istic. The  skin  at  first  is  dry,  wrinkled,  and  grayish  white 
in  color;  later  it  becomes  darker  and  more  shriveled.  At 
the  junction  of  the  living  and  dead  tissue  there  is  some 


GANGRENE  175 

hyperemia,  and  eventually  a  line  of  demarcation  forms. 
As  it  is  difficult  to  tell  how  much  is  actually  destroyed, 
it  is  proper  to  wait  for  the  line  of  demarcation  before 
amputation  is  performed.  As  a  rule  there  is  but  little. 
In  no  one  of  the  cases  the  author  has  seen  has  there  been 
any  swelling  of  the  proximal  part,  but  such  swelling  has 
been  described  in  some  cases.  The  condition  is,  as  a  rule, 
similar  to  a  typical  case  of  dry  gangrene.  Various  explana- 
tions have  been  given  as  to  the  occurrence  of  gangrene 
under  the  conditions  mentioned.  It  may  follow  the  use 
of  solutions  as  weak  as  one-  or  two-percent  strength.  It 
has  been  suggested  that  some  individuals  have  an  idio- 
syncrasy, and  are  locally  much  more  susceptible  to  the  hurt- 
ful action  of  the  drug  than  are  others,  and  that  in  them 
stasis,  followed  by  thrombosis,  occurs  more  readily,  and 
gangrene  results.  It  is  a  fact  that  the  portion  which 
becomes  gangrenous  is  generally  a  terminal  part  of  the 
body — for  example,  a  finger  or  a  toe. 

Diabetic  Gangrene. — Encouraging  results  are  some- 
times obtained  in  this  usually  incurable  condition  from  the 
administration  of  nuclein.  Locally,  mild  antiseptic  appli- 
cations are  indicated.  If  amputation  is  to  be  advised  it 
must  be  early  and  far  above  the  site  of  local  lesions;  it 
may  be  made  under  a  single  dose  of  the  hyoscine-morphine- 
cactin  anesthetic,  plus  cocaine  locally. 

Internal  Medication  in  Gangrene. — While  it  is 
true  that  very  little  can  be  done  for  gangrene  (even  diabetic) 
by  internal  medication,  it  is  equally  true  that  some  kind  of 
medicine  must  be  given  or  patient  and  friends  will  be  dis- 
satisfied and  some  surgeon  found  who  knows  enough  to 
treat  a  patient  as  well  as  treat  a  disease!  Of  drugs  advised 
probably  first  choice  should  fall  on  nuclein — one  of  the 
"  defensive  proteids  "  of  the  living  body — which  has  recently 
been  much  employed  in  general  debility,  the  dose  of  which 
is  from  two  to  five  drops  of  the  solution  or  one  to  three 


176  SURGICAL  THERAPEUTICS 

of  the  two-drop  tablets  in  which  it  may  be  obtained.  Four 
doses  a  day  may  be  given.  Alcohol  may  be  of  benefit  in 
some  cases,  but  as  a  rule  one-twentieth  grain  of  sulphate 
of  strychnine  four  times  a  day  will  better  hold  up  the  pa- 
tient's strength.  The  "triple  arsenates" — arsenate  of 
strychnine,  arsenate  of  quinine  and  arsenate  of  iron,  one 
milligram  of  each  (gr.  1-67)  four  times  a  day — give  much 
satisfaction  in  keeping  the  patient  from  sinking  before 
"demarcation"  occurs,  if  that  is  to  be  waited  for. 

GASTRIC  ULCER 

Before  resorting  to  surgical  treatment  the  Lenhartz 
method  should  be  tried.  It  is  as  follows:  (i)  Absolute 
rest  in  bed  for  at  least  four  weeks;  (2)  avoidance  of  all 
mental  excitement;  (3)  almost  constant  use  of  ice-bags 
over  the  stomach  for.  two  weeks;  (4)  daily  administration 
of  from  200  to  300  Cc.  of  iced  milk  by  spoonful  and  two 
to  four  beaten  eggs;  (5)  the  use  for  ten  days  of  2  Gm. 
(30  grains)  of  bismuth  subnitrate  at  a  dose.  Importance 
is  attached  to  the  use  of  beaten  eggs.  They  are  beaten 
whole  with  a  little  sugar  and  kept  in  contact  with  ice. 

Feeding. — The  strength  must  be  maintained  by 
nutrient  enemas,  and  by  good  claret,  iced,  swallowed  in 
small  quantities  at  frequent  intervals.  After  the  stomach 
has  rested  for  a  few  days  foods  which  are  digested  chiefly 
in  the  intestine  may  be  guardedly  tried.  Excision  of 
the  ulcer  is  justifiable. 

Gelatin  for  Gastric  Hemorrhage. — Excellent  re- 
sults are  reported  in  the  treatment  of  gastric  and  intes- 
tinal hemorrhage  by  the  internal  administration  of  a 
preparation  of  fluid  gelatin.  Prompt  effect  of  the 
remedy  in  such  cases  as  typhoid  fever,  gastric  carcinoma, 
ulcer  of  the  stomach,  and  melena  has  been  reported.  In 
none  of  these  cases  was  any  other  medicine  resorted  to 
except  the  gelatin  treatment,  yet  prompt  cessation  of 


GASTRIC  ULCER  177 

the  bleeding  followed  in  nearly  all.  The  formula  for  this 
gelatin  mixture  is  as  follows:  20  grams  of  gelatin  is  boiled 
during  six  hours  with  enough  water  to  make  130  cubic 
centimeters.  It  then  remains  fluid,  and  2  grams  of  citric 
acid  is  added.  It  may  be  flavored  with  a  little  syrup 
of  orange,  and  is  given  in  doses  of  one  or  two  tablespoon- 
fuls  every  two  hours. 

Removal  of  Gastric  Ulcer. — It  is  far  better,  when 
possible,  to  remove  the  ulcers  near  the  pylorus  (even 
though  there  be  three  or  four)  than  to  make  a  gastro- 
jejunostomy.  If  they  can  be  excised  without  danger 
of  causing  cicatricial  stricture  of  the  pylorus,  the  advan- 
tages of  simple  excision  are  that  the  site  of  the  disease 
(and  the  source  of  hemorrhage)  is  removed,  the  normal 
relation  of  the  viscera  is  not  disturbed,  convalescence  is 
speedier  and  the  ultimate  results  are  better.  Of  course 
if  there  be  great  dilation  of  the  stomach  it  wJll  be  better  to 
make  a  gastroenterostomy  at  the  lowest  part  of  the  stomach, 
but  on  account  of  the  danger  of  formation  of  "vicious 
circle"  it  should  be  avoided  whenever  possible.  Ulcers 
of  the  duodenum  should  be  treated  in  the  same  way. 

To  Check  Hemorrhage. — The  patient  must  be 
kept  perfectly  quiet,  a  small  dose  of  morphine  being 
injected  if  necessary.  Ergot  is  advised  by  some  but 
must  not  be  continued  if  it  cause  vomiting,  as  vomiting 
is  a  source  of  great  danger.  Small  pieces  of  ice  may  be 
swallowed,  whole. 

To  Check  Pain. — When  patients  will  not  submit  to 
operative  treatment  for  gastric  ulcer  the  pain  may  be 
controlled  far  better  than  by  the  use  of  morphine  by 
simply  having  the  patient  take  a  teaspoonful  of  bicarbo- 
nate of  sodium  in  lime  water,  with  a  few  drops  of  essence 
of  peppermint  added. 

To  Stop  Vomiting. — Bismuth  subnitrate  may  be 
given  by  the  stomach;  but  the  best  way  is  to  give  2  grams 


178  SURGICAL  THERAPEUTICS 

(30  grains)   each  of   chloral  and  potassium  bromide   in 
four  ounces  of  water,  by  the  rectum. 

GAUZE:    THE  CARE  OF 

While  it  costs  more,  it  is  best  to  buy  plain,  sterilized 
gauze,  as  well  as  bichloride  gauze,  in  one-yard  packages, 
for  use  in  minor  surgery  and  for  dressing  of  wounds  which 
mnst  be  kept  aseptic.  For  use  at  operations  five-yard 
rolls  in  pasteboard  boxes  (hermetically  sealed  after  sterili- 
zation) are  best;  but  if  the  operation  be  one  of  magni- 
tude, such  as  abdominal  section,  pieces  should  be  cut 
from  the  roll  and  boiled  at  the  time  .  of  operation.  If 
any  part  of  a  roll  be  left  it  should  be  carefully  wrapped 
up  in  the  clean  container  in  which  it  came  and  saved 
for  dressing  infected  cases. 

The  average  doctor  buys  a  jar  containing  five  yards 
of  gauze,  opens  it,  cuts  off  what  he  needs  with  scissors 
taken  from  an  instrument-case  or  satchel,  and  says  he 
has  used  an  "aseptic"  dressing.  This  is  not  true  unless 
the  shears  be  taken  out  of  the  sterilizer  or  boiler,  for  they 
have  become  contaminated  in  the  satchel  or  case;  even 
letting  them  lie  in  alcohol  for  a  few  minutes  does  not 
insure  sterility.  After  the  jar  has  once  been  opened 
and  some  of  the  gauze  cut  off,  the  remainder  is  not  strictly 
sterile  and  should  never  be  used  as  a  dressing  for  a  per- 
fectly clean  wound;  hence  the  advice  to  buy  in  yard 
packages  for  strictly  aseptic  cases. 

A  large,  clean  jar  should  be  kept  in  every  surgeon's 
dressing-room  into  which  the  remains  of  these  yard  pieces 
may  be  thrown,  because  some  wounds  do  not  require  a 
full  yard  or  full  two  yards,  and  these  small  pieces  may 
be  employed  for  dressing  infected  wounds.  It  is  really 
better  to  have  one  dry  jar  and  one  containing  i  in  2000 
corrosive  sublimate  solution,  or  i  in  40  phenol  solution, 
so  that  one  may  have  constantly  at  hand  both  dry  and 


GLEET  179 

moist  gauze  for  infected  wounds.  When  an  operation 
is  performed  in  a  private  house  the  packages  should  not 
be  opened  until  the  instruments  are  to  be  boiled;  any 
left-over  gauze  may  be  wrung  dry  and  carried  to  the  office 
to  add  to  the  moist-jar;  but  if  the  case  has  been  one  of  bad 
pus-infection  the  remaining  gauze  must  be  boiled  twenty 
minutes  before  dropping  into  the  moist  jar  even  though 
the  solution  be  strongly  germicidal.  Too  much  attention 
cannot  be  exercised  in  the  care  of  gauze  for  dressings. 

GENITOURINARY  SUPPURATION 

Infections  of  the  genitourinary  tract  attended  by  the 
formation  of  pus  are  greatly  lessened  in  virulence  by 
small  quantities  of  formaldehyde,  a  drug  which  is  excreted 
chiefly  by  the  kidneys.  Pyelitis,  pyelonephrosis,  cystitis, 
prostatitis  and  even  gonorrheal  urethritis  speedily  improve 
after  its  administration.  A  most  excellent  combination 
for  each  of  these  diseases  is: 

Formin 0.2    (grs.  3    ) 

Arbutin 0.04  (gr.    1-2) 

Ammonium  benzoate 0.2    (grs.  3    ) 

One  such  tablet  is  to  be  taken  in  from  four  to  eight 
ounces  of  water  every  three  to  six  hours.  From  it  formalde- 
hyde is  generated  slowly,  and  gradually  eliminated  through 
the  kidneys,  thus  exercising  an  antiseptic  action  from 
the  very  glomeruli  of  the  kidney  to  the  end  of  the  tractus 
genitalis. 

GLEET 

Under  the  name  "gleet"  are  included  (a)  the  discharge 
(often  only  a  "morning  drop"  obtained  by  stripping  the 
urethra)  of  a  chronic  urethritis,  and  (b)  the  mucopurulent 
discharge  accompanying  recent  strictures.  Both  were 
formerly  regarded  as  of  minor  importance  and  were  not 
considered  a  bar  to  marriage.  Now  it  is  known  that  such 


180  SURGICAL  THERAPEUTICS 

discharges  are  a  menace  to  the  happiness,  and  often  the 
life,  of  any  woman  previously  free  from  infection  with  whom 
the  patient  may  have  intercourse;  so  long  as  there  is  a 
morning  drop,  so  long  as  clap-shreds  are  to  be  seen  in  the 
morning  urine,  there  is  danger  of  infection  and  the  victim 
should  not  be  permitted  to  marry. 

If  there  is  a  stricture  it  should  be  treated  by  proper 
measures.  (See  "Stricture.")  But  usually  the  gleet  depends 
upon  a  chronic  urethritis  or  at  least  an  infection  of  some 
of  the  deep  follicles  of  the  urethra,  or  upon  an  ulcerated 
spot  within  an  inch  or  two  of  the  meatus  externus.  When 
passage  of  a  sound  shows  no  stricture  and  when  the  endo- 
scope  reveals  no  ulcer  within  the  first  two  inches  of  the 
urethra  it  may  be  taken  for  granted  that  the  discharge  is 
due  to  a  chronic  inflammation,  and  an  injection  ordered 
as  follows: 

Zinc  sulphate    i  .o 

Lead  acetate i  .o 

Alum    i  .o 

Water 160.0 

Mix  and  use  as  an  injection  thrice  daily.  At  first  the  dis- 
charge will  increase,  but  in  from  3  to  6  weeks  the  trouble 
will  entirely  disappear — in  the  favorable  cases. 

Ricord's  formula  is  still  a  favorite  with  some  genito- 
urinary surgeons:  two  parts  of  rose  water  to  one  part  of 
claret  wine,  lessening  the  amount  of  water  daily  until  full- 
strength  wine  can  be  tolerated  as  an  injection. 

When  the  discharge  does  not  yield  to  these  injections 
there  is  some  point  of  granulation  which  must  be  found 
by  repeated  endoscopic  examinations,  and,  when  detected, 
cured  by  passing  graduated  steel  sounds  beyond  the  abraded 
surface,  three  or  four  times  a  week ;  or  later,  if  necessary, 
by  burning  with  a  25-percent  solution  of  nitrate  of  silver, 
through  an  endoscope,  by  means  of  a  little  cotton  on  the 
end  of  a  probe. 


GOITER  181 

The  urine  should  be  kept  non-irritating  by  use  of  arbu- 
tin  or  similar  remedies. 

GLOSSITIS 

Inflammation  of  the  tongue  of  very  serious  character 
sometimes  follows  slight  injury,  as  from  injudicious  seizure 
with  forceps  by  an  excitable  and  not  too  wise  anesthetizer; 
and  it  may  arise  from  systemic  infection,  sometimes  with 
enormous  swelling,  high  fever,  great  discomfort  and  some 
danger.  Locally  antiseptic  mouth-washes  are  valuable, 
potassium  chlorate  being  good  in  saturated  solution  with 
a  little  phenol  added;  or  the  patient  may  be  given  frequently, 
to  suck,  a  "menthol  compound"  tablet,  to  be  had  of 
manufacturing  chemists,  of  this  composition: 

Boric  acid     02  (gr.  1-4  ) 

Benzoic  acid 02  (gr.  1-4  ) 

Sodium  fluoride    04  (gr.  1-2  ) 

Sodium  bisulphide   04  (gr.  1-2  ) 

Thymol    04  (gr.  1-2  ) 

Menthol 04  (gr.  1-2  ) 

Eucalyptol 04  (gr.  1-2  ) 

Camphor   005  (gr.  1-16) 

Hydrastine    005  (gr.  1-16) 

This  is  a  non-toxic,  alkaline  antiseptic  which  may  be  used 
freely.  The  bowels  must  be  emptied  quickly  with  calomel 
and  podophyllin  followed  by  saline  laxative;  and  rectal 
feeding  then  instituted,  as  the  patient's  strength  often  fails 
rapidly. 

GOITER 

Patients  affected  with  goiter  often  want  to  take  medi- 
cine in  addition  to  the  local  application  of  iodine  (tinc- 
ture or  the  decolorized  tincture).  Potassium  iodide, 
half  a  gram,  thrice  daily,  seems  to  hasten  subsidence  of 
the  swelling  in  some  cases.  Other  patients  take  iodo- 
form  with  apparent  advantage,  in  a  capsule  or  tablet, 


182  SURGICAL  THERAPEUTICS 

one  centigram  three  to  six  times  a  day.  Phytolaccin  (the 
active  principle  of  phytolacca  decandra)  has  been  lauded, 
and  is  given  in  doses  of  one  centigram  (1-6  grain)  four 
times  a  day.  Strict  attention  should  be  paid  to  diet, 
rich  foods  being  prohibited,  and  the  bowels  kept  active 
— securing  at  least  two  movements  daily,  by  the  use  of 
salines  and  an  aloin  pill.  Donovan's  solution  was  much 
used  long  ago,  but  arsenic  iodide,  one  milligram  (1-67 
grain)  four  times  a  day,  will  be  found  more  agreeable. 

Exophthalmic  Goiter* — Physiologists,  pathologists 
and  surgeons  now  all  agree  with  the  statement  of 
Hartley  that  "clinically"  it  makes  no  difference 
whether  the  secretion  of  the  thyroid  gland  is  increased 
or  is  chemically  altered  as  the  result  of  changes  in  the 
blood,  in  the  alimentary  canal,  or  in  the  central  nervous 
system;  the  fact  remains  that  "the  removal  of  the 
growing  gland  does  away  with  the  symptoms,  and  upon 
the  failure  to  remove  the  diseased  gland  depends  no  cure." 
It  is,  of  course,  best  that  medicinal  treatment  should 
precede  surgical  interference,  because  of  the  undoubted 
cures  that  have  taken  place.  This  treatment  may  be 
combined  with  the  use  of  the  x-ray  (Mayo)  or  with  the 
administration  of  milk  or  serum  from  thyroidectomized 
goats,  sheep,  etc.  (Lanz  and  Moebius.)  This  method 
of  treatment  should  not  be  continued  too  long,  unless 
operative  treatment  is  contraindicated,  since  the  disease 
itself  tends  to  diminish  the  vital  resistance  and  to  exhaust 
the  nerve-centers.  The  earlier  the  diagnosis  and  the  opera- 
tion, the  easier  the  operation,  and  the  less  dangerous  and 
difficult  the  after-treatment.  Hartley  found  that  the  severer 
types  derive  great  benefit  from  rest  in  bed  for  two  or  three 
weeks  previous  to  the  operation.  The  nervous  excita- 
tion, the  tachycardia,  and  the  muscular  tremor  are  so 
much  improved  that  operation  is  often  undertaken  under 
much  more  favorable  conditions. 


GOITER  183 

Just  what  cases  should  be  subjected  to  operation  has 
not  been  decided,  though  as  a  broad  rule  it  may  be  said 
that  when  the  bronchocele  is  the  most  prominent  fea- 
ture and  when  internal  medication  by  iodides,  tincture 
of  strophanthus,  digitalin,  etc.  fails,  thyroidectomy  is  to 
be  advised.  On  the  other  hand,  if  exophthalmos  and 
tachycardia  be  most  prominent,  excision  of  the  superior 
and  middle  gangalia  of  the  cervical  sympathetic  is  to  be 
preferred. 

Recently  a  serum  treatment  has  been  employed  with 
excellent  effect  in  a  few  cases.  It  is  prepared  by  inject- 
ing the  purined  neucleoproteids  of  the  thyroid  into  some 
animal:  a  rabbit  or  sheep.  Beebe,  of  New  York,  reports 
that  the  serum  treatment  causes  an  increase  in  the  per- 
centage of  hemoglobin  and  the  number  of  erythrocytes, 
(possibly  due  to  the  general  health  improvement  and  not 
to  any  direct  action  on  the  blood-forming  organs).  The 
therapeutic  use  of  the  serum  is  based  on  the  theory  that 
exophthalmic  goiter  is  a  toxemia  and  the  toxin  in  ques- 
tion is  a  thyreoglobulin.  This  theory  best  explains  the 
striking  results  obtained  in  some  acute  cases  with  soft 
thyroids,  probably  in  a  simple  state  of  hypertrophy  and 
containing  a  large  amount  of  colloid  matter  with  but  a 
slight  number  of  cells. 

The  majority  of  cases,  however,  are  of  the  chronic 
type  and  do  not  show  at  once  this  rapid  improvement. 
The  gland  is  more  cellular  and  the  cytotoxic  element  in 
the  serum,  in  the  small  doses  given,  is  probably  too  feeble 
to  cause  immediate  or  rapid  diminution  of  the  gland. 
More  rapid  destruction,  moreover,  might  be  dangerous 
in  these  cases.  There  is  some  reason  to  think  that  the 
serum  does  have  a  cytolytic  effect;  the  main  fact  is  that 
there  is  a  reduction  in  the  size  of  the  gland,  and  in  a  few 
cases  it  has  been  restored  to  apparently  normal  size.  Con- 
sidering all  the  facts,  Beebe  thinks  it  fair  to  conclude 


184  SURGICAL  THERAPEUTICS 

that  the  serum  has  considerable  value  in  the  medical 
treatment  of  exophthalmic  goiter.  The  improvements 
and  cures  under  its  use  have  been  too  numerous  to  be 
ascribed  to  coincidence,  and  he  believes  that  under  favor- 
able conditions  much  can  be  accomplished  by  careful 
serum  therapy.  Of  internal  remedies  best  results  have 
been  obtained  from  the  use  of  hydrobromide  of  quinine. 
From  one  to  two  grams  (15  to  30  grains)  must  be  given 
every  24  hours  for  a  long  time — preferably  in  four  to  six 
doses. 

Operation  for  Goiter. — Extensive  experience  cor- 
roborates the  assertion  of  Hardon,  who  has  made  a  care- 
ful study  of  the  subject,  (i)  Every  irregular  tumor  of 
the  thyroid,  no  matter  how  small,  should  be  removed, 
as  only  by  following  this  line  of  procedure  can  we  hope 
to  save  the  lives  of  those  having  malignant  growths.  (2) 
Every  regular  tumor  of  the  thyroid  causing  symptoms 
other  than  deformity,  should  be  resected  when,  after  a 
few  months'  medical  treatment,  its  growth  is  not  checked, 
and  no  improvement  is  shown.  (3)  Avoidance  of  trauma, 
care  of  the  stump,  free  drainage  and  salt  solution  to  keep 
full  blood-  and  lymph-vessels,  to  prevent  as  far  as  pos- 
sible wound  absorption,  constitute  the  chief  points  in 
operation. 

Operation  in  Exophthalmic  Goiter. — One  must  re- 
member that  the  worst  cases  are  sometimes  those  in 
which  no  exophthalmos  is  present.  Operation  is  the  only 
cure  yet  known;  it  is  not  dangerous  if  done  under  hyoscine- 
morphine  anesthesia,  plus  cocaine  locally,  with  clean  hands 
and  in  properly  selected  cases.  But  thyroidectomy  should 
never  be  attempted  in  any  case  when  the  patient  has  a 
dilated  heart  or  an  endocarditis  of  long-standing.  Cases 
most  favorable  for  operation  are  those  in  which  the  gland 
is  more  enlarged  upon  one  side  than  the  other;  those  in 
which  there  is  a  definite  tumor  formation;  those  in  which 


GONORRHEA  185 

the  gland  is  not  excessively  vascular;  and  those  in  which 
the  enlargement  has  preceded  the  Graves'  symptoms  for 
months  or  years.  Like  other  goiters  the  bronchocele  of 
Graves'  disease  is  'often  benefited  by  the  local  use  of  iodine. 

Removal  Under  Local  Anesthesia. — In  some  cases 
conditions  are  such  that  removal  is  not  possible  under 
general  anesthesia.  Here  one  may  inject  one  dose  of 
hyoscine  (gr.  i-ioo)  and  morphine  (gr.  1-4)  an  hour  before 
operation  and  then  use  a  local  anesthetic.  The  solution 
best  to  be  employed  consists  of  sodium  chloride,  12  grains, 
beta  eucain,  3  grains,  water  3  1-2  ounces.  This  is  boiled 
and  then  10  minims  of  commercial  adrenalin  solution 
are  added.  The  solution  is  ready  for  use  as  soon  as 
cooled. 

Treatment  by  Iodine. — Bronchocele  not  sufficiently 
prominent  to  demand  excision  may  be  greatly  reduced 
by  the  use  of  iodine.  Perhaps  the  best  way  is  to  apply 
externally,  by  means  of  a  camelshair  brush — using  tinct- 
ure of  iodine  to  which  has  been  added  just  enough  aqua 
ammonia  to  decolorize.  A  little  of  this  "colorless  tincture 
of  iodine"  used  twice  daily  will  often  cause  almost  total 
disappearance  of  a  goiter  not  cystic.  It  may  also  be  made 
to  enter  the  deep  tissues  by  cataphoresis  (negative  pole 
of  a  galvanic  battery),  enabling  one  to  get  speedier  results. 
Or  from  five  to  fifteen  minims  may  be  injected  into  the 
fibrous  tissue  by  hypodermic  syringe.  Great  care  must 
be  exercised  in  such  injections  because  if  the  iodine  is 
thrown  into  the  connective  tissue  instead  of  the  gland, 
ulceration  will  follow,  with  ugly  scar-formation. 

GONORRHEA 

A  urethritis  due  to  infection  with  Neisser's  coccus  (gono- 
coccus)  is  an  acute  inflammation  which  requires  six  weeks' 
treatment  in  the  first  attack,  and  ^rom  two  to  three  weeks 
in  subsequent  ones. 


186  SURGICAL  THERAPEUTICS 

During  the  early  stage,  when  the  inflammation  is  limited 
to  the  anterior  urethra,  the  best  treatment  consists  of  inter- 
nal remedies  calculated  to  make  the  urine  bland  and  unir- 
ritating;  but  if  the  patient  insists  upon  having  an  injection 
from  the  first  he  must  be  instructed  not  to  throw  it  in  far, 
as  by  so  doing  he  will  force  the  pus  into  the  deep  urethra 
and  by  so  doing  may  cause  posterior  urethritis  or  even 
cystitis. 

Irrigation  treatment  is  advised  by  most  writers;  it  should 
not,  however,  be  used  indiscriminately  but  reserved  for 
cases  in  which  the  deep  urethra  is  involved.  Permanganate 
of  potassium  is  used  in  mild  solution. 

During  the  acute  stage,  when  the  penis  is  swollen  and 
edematous,  with  redness  and  eversion  of  the  meatus  and 
great  tenderness  in  the  urethra,  injections  do  much  harm; 
if  anything  is  used  it  should  be  of  the  mildest  kind,  like  one 
or  two  grains  of  alum  to  an  ounce  of  water  and  a  little  aqueous 
extract  of  opium.  Excellent  results  are  obtainable  from 
injection  of  a  one-percent  cocaine  solution  with  two-per- 
cent phenol  added,  about  five  minutes  before  each  passage 
of  urine.  Later,  when  the  severe  symptoms  of  infection 
have  subsided  and  the  discharge  becomes  copious,  the 
stronger  injections  may  be  ordered,  three  grains  each  of 
alum,  acetate  of  lead  and  sulphate  of  zinc  to  the  ounce 
of  water  giving  the  best  results  of  any.  At  first  this  may 
be  used  four  times  a  day;  the  second  week  three  times, 
the  third  only  three,  and  the  fourth  only  at  night,  unless 
the  discharge  ends  in  gleet  (which  see). 

Internal  treatment  is  important.  In  the  early  stage 
salicylate  of  phenol  (salol)  is  by  all  odds  the  best  remedy. 
With  it  cubebs  may  be  combined,  a  remedy  which  distinctly 
modifies  ardor  urines: 

Phenol  salicylate    8.0  (drs.  2) 

Oleoresin  of  cubebs 4.0  (dr.    i) 

Codeine  sulphate  0.2  (grs.  3) 


GONORRHEA  187 

Mix  and  make  sixteen  capsules.  Direct:  One  every 
four  hours.  The  codeine  may  be  reduced  a  half  in  the 
second  prescription  and  elided  altogether  in  the  third. 

Potassium  bromide  at  bedtime  is  good  to  produce  sleep 
and  limit  chordee;  dose  one  to  two  grams  (15  to  30  grains); 
or  lupulin  may  be  given  in  the  dose  of  two  grams  (Hare). 
Opium  and  belladonna  suppositories  may  be  ordered  if 
indicated. 

Potassium  citrate  in  ten-grain  tablet,  to  be  dissolved 
in  a  glass  of  water  and  taken  two  hours  after  each  meal, 
is  excellent  after  the  first  week,  though  the  salol  may  also 
be  continued. 

When  fever  is  present  (in  the  first  few  days)  aconitine 
is  indicated.  A  milk  diet  aids  in  affording  relief  at  this 
stage;  and  an  unirritating  diet  is  essential  throughout. 

When  the  posterior  urethra  is  affected  the  irrigation 
treatment  is  indicated.  This  is  done  with  weak  solution 
of  potassium  permanganate,  having  a  pale  wine-color. 
A  fountain  syringe  is  filled  with  this,  a  blunt  nozzle  applied 
and  pressed  into  the  mouth  of  the  urethra  as  the  fluid  begins 
to  flow.  The  patient  is  directed  to  relax  himself  perfectly 
just  as  if  beginning  to  urinate,  when  the  fluid  will  readily 
flow  into  the  bladder,  filling  it  to  the  limit;  this  is  expelled 
and  another  bladderful  introduced,  and  so  on  until  at  least 
two  quarts  of  the  hot  solution  are  used.  This  is  repeated 
two  or  three  times  daily. 

The  bowels  must  be  kept  open,  the  diet  regulated,  and 
as  little  exertion  as  possible  enjoined  until  the  disappear- 
ance of  acute  symptoms.  Here  copaiba  seems  excellent 
and  oil  of  sandalwood  (each  in  capsule)  gives  much  satis- 
faction. 

When  the  posterior  urethritis  is  at  its  height  opium 
and  belladonna  suppositories  are  almost  a  necessity;  or  if 
they  constipate  too  much  a  clyster  of  four  ounces  of  starch 
water  containing  two  grams  (30  grains)  each  of  potassium 


188  SURGICAL  THERAPEUTICS 

bromide  and  chloral  hydrate  may  be  given  at  bedtime  for 
several  nights.  In  the  worst  cases  codeine  or  morphine 
must  be  given,  though  with  care. 

Chronic  gonorrhea  usually  means  either  a  granular 
spot  which  must  be  burned  with  silver  through  an  endo- 
scope  or  a  stricture  which  must  be  treated  with  sounds  or 
otherwise.  (See  "Gleet".)  The  "candle  drainage  bougies" 
are  excellent  in  many  cases. 

Gonorrhea:  Lingering. — After  a  gonorrhea  has  run 
for  five  or  six  weeks  the  patient  becomes  uneasy  and  wants 
"something  better."  To  such  a  one,  and  to  the  man  with 
"gleet"  the  following  may  be  given: 

Alum  0.8 

Lead  acetate  0.8 

Zinc  sulphate 0.8 

Glycerin 16.0 

Water 112.0 

Direct:  Use  as  an  injection  three  or  four  times  a  day. 
Shake  well  before  using;  hold  the  injection  two  minutes 
if  possible.  Chemists  claim  that  this  prescription  should 
not  be  written,  since  it  contains  "incompatibles"  and  a 
precipitate  is  formed.  This  is  exactly  what  is  wanted;  it 
is  the  retention  of  some  of  this  precipitate  in  the  urethra 
for  hours  which  does  the  good. 

Gonorrhea  in  Women. — For  the  vulvovaginitis  due 
to  Neisser's  coccus  one  may  use  an  injection  twice  a  day 
of  a  quart  of  i  in  2000  or  i  in  4000  solution  of  potassium 
permanganate  in  hot  water,  followed  by  a  solution  of  mer- 
cury bichloride  i  in  2000,  and  a  dressing  of  5  percent 
ichthyol  in  glycerin.  Resorcin,  in  doses  of  i  gram  (15 
grains)  may  be  given  internally,  three  times  daily,  with 
advantage.  Twice  a  week  silver  nitrate,  ten  grains  to  the 
ounce  of  water,  should  be  used  to  swab  the  mucous  mem- 
brane, and  following  this,  a  powder  of  alum,  3  parts,  tannin, 
2  parts,  should  be  insufflated.  Frequent  bathing  and  other 


HANDS  189 

hygienic  means  should  be  employed.  If  there  is  compli- 
cating cervicitis  and  metritis,  dressings  of  ichthyol,  10 
parts,  iodoform  5  parts,  glycerin,  200  parts,  should  be 
used.  Local  applications  of  tincture  of  iodine  or  of  zinc 
chloride,  i  in  50,  may  be  employed,  and  intrauterine 
injections  of  about  i  1-2  ounces  of  the  following  solution: 
Alum,  2  1-2  parts;  tincture  of  iodine  and  alcohol,  each  25 
parts.  Urethritis  should  be  treated  by  the  balsams,  the 
alkalis,  and  by  irrigations  of  silver  nitrate  or  protargol 
solutions,  or  a  i-percent  aqueous  solution  of  thallin  sulphate. 

HANDS 

Acute  Phlegmons  of  the  Hand. — According  to 
Knavel  there  are  five  great  spaces,  with  their  tributaries, 
in  which  pus  can  accumulate  in  phlegmons  of  the  hand: 
First,  the  dorsal  subcutaneous,  which  is  an  extensive  area 
of  loose  tissue,  without  definite  boundaries,  allowing  pus 
to  spread  over  the  entire  dorsum  of  the  hand.  Second,  the 
dorsal  subaponeurotic,  limited  upon  its  subcutaneous  side 
by  the  dense  tendinous  aponeurosis  of  the  extensor  tendons, 
upon  the  deep  side  by  the  metacarpal  bones,  having  the 
shape  of  a  truncated  cone,  with  the  smaller  end  at  the 
wrist  and  the  broader  at  the  knuckle.  Laterally  the  apo- 
neurotic  sheet  shades  off  into  the  subcutaneous  tissue. 
Third,  the  hypothenar  area,  a  distinctly  localized  space. 
Fourth,  the  thenar  space,  occupying,  approximately,  the 
area  of  the  thenar  eminence,  to  the  flexion-adduction  crease 
of  the  thumb,  not  going  to  the  ulnar  side  of  the  middle 
metacarpal.  It  should  be  remembered  that  this  space 
lies  deep  in  the  palm,  just  above  the  abductor  transversus. 
Fifth,  the  middle  palmar  space,  with  its  three  diverticula 
below  along  the  lumbrical  muscles,  limited  by  the  middle 
metacarpal  bone  upon  the  radial  side,  overlapped  by  the 
ulna  bursa  upon  the  ulnar  side,  and  separated  from  the 
thenar  space  by  a  partition  which  is  very  firm  everywhere 


190  SURGICAL  THERAPEUTICS 

except  at  the  proximal  end,  where  it  is  rather  thin.  A 
small  isthmus  can  be  found  leading  from  the  proximal 
end  of  the  space  under  the  tendons  and  ulna  bursa  at  the 
wrist  up  into  the  forearm. 

Defective  Hand  Cleaning. — In  attempting  to  secure 
asepsis  of  the  hands  for  operation  or  dressing  of  wounds  the 
surgeon  is  apt  to  scrub  inadequately  two  parts  of  the  hands : 
the  center  of  the  palm  and  the  spaces  between  the  fingers 
near  their  base.  Of  course  the  chief  danger  is  in  the  dirt 
under  the  finger-nails  and  around  the  roots  of  the  nails, 
but  the  other  two  points  should  always  be  remembered. 

Eczema  of  the  Hands. — By  reason  of  much  scrubbing 
and  enforced  application  of  hot  water  to  the  hands,  many 
surgeons  develop  eczema  of  the  hands — especially  those 
who  use  the  potassium  permanganate  and  oxalic-acid  solu- 
tions. No  application  has  proved  so  serviceable  in  keeping 
the  skin  soft,  supple  and  pliable  as  the  oleate  of  bismuth 
ointment,  the  composition  of  which  is  as  follows: 

Bismuth  oxide 4.0  (dr.    i) 

Oleic  acid 32.0  (oz.    i) 

White  wax 12.0  (drs.  3) 

Vaseline 64.0  (ozs.  2) 

The  addition  of  a  few  drops  of  the  oil  of  rose  renders 
the  ointment  more  agreeable. 

Neuroma  of  Hand. — Quite  frequently  piano  players, 
telegraphers  and  others  who  make  constant  use  of  their 
fingers  develop  neuromas  between  the  metacarpal  bones — 
small,  painful  tumors  of  a  few  months'  growth.  These 
should  be  removed  under  cocaine  with  most  careful  anti- 
septic precautions  lest  thecitis  or  neuritis  be  set  up.  Great 
care  must  be  exercised  not  to  injure  the  nerve. 

Phenol  Solution  for  the  Hands. — Some  doctors 
claim  that  solutions  of  bichloride  of  mercury  make  the 
hands  too  rough  if  used  frequently.  For  these  a  solution 
of  phenol  may  be  substituted,  though  it  is  not  so  effective. 


HANDS  191 

To  be  of  any  use  whatever,  it  must  be  made  as  strong  as 
i  in  40  for  the  hands  (and  i  in  20  for  cleaning  the  skin  to 
be  cut).  That  means  one  full  ounce  of  liquefied  phenol 
(95-percent  carbolic  acid  of  the  old  Pharmacopeia)  to  a 
little  more  than  a  quart  of  water.  Indeed,  it  is  better  to 
use  one  ounce  to  the  quart,  to  be  sure  that  no  mistake 
is  made  and  a  useless  solution  employed.  If  the  hands  be 
dipped  in  this  solution  during  the  course  of  an  abdominal 
section  they  must  be  rinsed  in  plain  water  before  being  put 
back  into  the  peritoneal  space.  Phenol  cannot  be  used 
often  upon  the  hands  without  serious  results. 

To  Clean  the  Hands  Quickly. — When  it  is  necessary 
to  clean  the  hands  quickly  (as  in  emergency  work,  or 
merely  to  make  a  hurried  dressing),  mix  equal  parts  of 
hydrogen  dioxide  and  liquor  potassae.  Scrub  the  hands  as 
carefully  as  possible;  then  of  this  mixture  pour  about  one 
teaspoonful  in  the  hollow  of  one  palm  and  thoroughly 
wash  the  hands  with  it.  Next  carefully  clean  the  nails, 
and  then  pouring  a  second  teaspoonful  the  same  as  before, 
saturate  the  nail-brush  and  go  over  the  whole  surface  of 
both  hands,  taking  special  care  to  scrub  under  and  around 
the  nails.  After  this  is  done  it  is  best  to  pour  the  third 
and  last  spoonful  in  the  hand  and  wash  thoroughly  in  it 
for  about  three  minutes.  Then  scrub  the  hands  thoroughly 
with  thymol  soap  (any  other  liquid  germicidal  soap  would 
do  as  well)  and  rinse  them  either  in  sterilized  water 
or  in  bichloride  solution  i  in  1000.  This  partial  steriliza- 
tion makes  the  hands  soft  and  white.  Experience  with 
this  method  shows  it  to  be  valuable  also  to  sterilize  the 
skin  of  patients  before  operations;  and  with  the  same  ease. 
It  is  well,  however — "to  make  assurance  doubly  sure" — 
to  wash  the  hands  for  two  minutes  in  dilute  alcohol,  one- 
third  water  to  two-thirds  alcohol,  before  the  final  rinsing. 

Turpentine  for  the  Hands. — Pure  oil  of  turpentine  is 
a  strong  antiseptic  and  is  very  useful  in  cleaning  the  hands 


192  SURGICAL  THERAPEUTICS 

for  operation  when  one  cannot  use  the  permanganate  of 
potassium  and  oxalic  acid  method  (which  ought  to  be 
employed  when  one  has  recently  had  the  hands  in  pus  and 
yet  must  operate).  It  is  generally  used  improperly.  The 
correct  procedure  is  to  scrub  the  hands  with  soft  soap  and 
warm  water — running  water  if  possible,  if  not,  the  bowl 
emptied  and  refilled  at  least  twice — for  at  least  five  minutes; 
then  to  dry  the  hands  thoroughly  upon  a  clean  (but  not 
necessarily  sterile)  towel;  and  then  to  cut  the  finger-nails 
"to  the  quick."  The  turpentine  is  then  poured  over  the 
hands  and  rubbed  in  thoroughly  around  the  roots  and  ends 
of  the  nails  and  between  the  fingers;  two  minutes  at  least 
being  devoted  to  this.  Finally  the  hands  and  finger-nails 
are  to  be  scrubbed  in  soap  and  clean  warm  water  and  then 
soaked  two  minutes  (by  the  watch)  in  65-percent  alcohol. 
They  are  then  ready  for  immersion  in  the  i  in  2000  sub- 
limate solution. 

HEMATEMESIS 

Vomiting  of  blood  may  be  from  (a)  an  injury  to  the 
stomach,  (b)  from  gastric  cancer  or  (c)  from  gastric  ulcer. 
Injury  to  the  stomach  by  penetrating  wound  means  an 
abdominal  section;  if  by  a  blow,  internal  medication  may 
be  relied  upon.  Hemorrhage  from  carcinoma  of  the 
stomach  can  be  treated  by  medicine  only.  Hematemesis 
dependent  upon  gastric  ulcer  should  be  treated  by  total 
abstinence  from  gastric  feeding  and  by  internal  remedies; 
if  it  occur  more  than  twice,  by  abdominal  section  and 
excision  of  the  affected  area,  with  cr  without  a  gastroen- 
terostomy,  as  indicated. 

Tho  non-operative  measures  are,  first,  swallowing  small 
pieces  of  ice,  whole. 

A  pill  containing  acetate  of  lead  in  dose  of  one  decigram 
(i  1-2  grains)  with  half  that  amount  of  pulverized  opium 
is  a  combination  employed  for  many  years. 


HEMOPHILIA  193 

One  and  a  half  grams  (23  grains)  of  tannic  acid  may  be 
given  in  three  or  four  capsules  and  repeated  in  an  hour 
if  needed;  but  it  sometimes  of  itself  excites  vomiting. 

Ergotin  may  be  given  every  half  hour  four  times,  but 
is  dangerous  in  the  dosage  usually  advised. 

Adrenalin  chloride,  hypodermically,  is  highly  com- 
mended. 

As  in  other  forms  of  hemorrhage,  a  full  dose  of  atropine, 
repeated  as  necessary,  controls  the  bleeding  better  than  any 
other  internal  remedy. 

Curative  Treatment* — If  hemorrhage  recur  again 
and  again,  abdominal  section  is  always  to  be  advised,  as 
in  most  cases  the  cause  of  hemorrhage  (unless  cancer)  can 
be  removed,  and  the  disease  thus  cured,  without  great 
danger. 

Oxide  of  Silver  for  Hematemesis. — Gastric  ulcer 
not  subjected  to  operative  treatment  may  lead  to  alarming 
hematemesis.  Silver  oxide  is  advised  to  control  the  bleed- 
ing, doses  of  a  centigram  (1-6  grain)  three  or  four  times  a 
day  giving  good  results  when  there  is  a  tendency  to  slight 
daily  recurrences.  It  not  only  acts  as  a  local  astringent 
but  it  is  said  to  be  a  powerful  nerve  sedative,  thus  helping 
to  allay  the  nervous  agitation  arising  from  fear;  and  this 
is  a  most  important  feature  of  many  cases. 

HEMOPHILIA 

This  subject  is  so  intimately  associated  with  surgery 
that  every  operator  must  have  it  in  mind  in  deciding 
about  operating  upon  a  stranger,  fatal  hemorrhage  having 
taken  place  more  than  once  from  a  trifling  incision.  Never- 
theless, conditions  sometimes  demand  operative  work, 
under  which  circumstances  the  dangers  must  be  fully 
explained.  Excessive  care  must  be  taken  as  to  hemo- 
stasis.  The  diseased  condition  is  amenable  to  treatment, 
the  Ions-continued  administration  of  calcium  chloride 


194  SURGICAL  THERAPEUTICS 

having  been  followed  by.  cure  in  some  instances.  Even 
the  arthritic  lesions  have  been  vastly  benefited  by  the 
same  remedy. 

Joint  Lesions  in  Hemophilia. — The  liability  of  the 
joints  to  become  affected  in  hemophilia  must  never  be 
forgotten  when  a  patient  complains  of  some  chronic  irri- 
tation of  a  joint.  The  symptoms  vary  according  to  the 
stage  of  the  disease,  and  may  be  grouped  in  three  classes: 
(i)  In  some,  intraarticular  hemorrhage  is  the  only  lesion; 
the  joint  suddenly  becoming  swollen  and  painful,  usually 
without  history  of  even  a  trifling  injury,  when  if  the  exis- 
tence of  hemophilia  is  known,  there  should  be  little  dif- 
ficulty in  recognizing  the  character  of  the  trouble — but  in 
case  of  doubt  aspiration  will  show  the  presence  of  blood 
and  make  the  diagnosis  unmistakable.  No  attempt 
should  be  made  to  evacuate  the  joint,  as  it  will  instantly 
refill.  Immobilization  and  internal  medication  are  the 
only  measures  indicated.  (2)  The  pain,  fever,  slight 
swelling  and  tenderness  subside  in  a  week  or  ten  days — 
when  if  treatment  is  unsuccessful,  there  is  recurrence  of 
the  hemorrhage  with  even  more  distention;  and  after 
several  repetitions  there  are  marked  articular  and  peri- 
articular  changes — thickenings — so  that  motion  becomes 
limited,  this  constituting  the  second  stage  of  the  arthro- 
pathy.  (3)  In  the  third  stage  there  is  complete  ankylosis 
— for  which  absolutely  nothing  can  be  done. 

HEMOPTYSIS 

Candler  advises  to  give,  at  once,  hypodermically, 
atropine  sulphate,  gr.  1-250.  Ergotin  or  sclerotonic  acid 
may  follow.  A  small  dose  of  morphine  will  quiet  patients; 
but  one  should  not  give  this  drug,  however,  till  hemor- 
rhage has  been  controlled,  and  then  not  let  the  patient 
know  morphine  is  given.  It  should  always  be  borne  in 
mind  that  ether  or  ethyl  chloride  sprays  to  nape  of  neck 


HEMORRHAGE  195 

and  over  the  sternal  notch  often  check  hemorrhage,  and 
nasal  sprays  of  liquor  ferri  subsulphatis,  one  dram  in 
eight  ounces  of  water,  will  prove  extremely  useful.  A 
certain  quantity  of  fine  spray  will  enter  the  bronchi. 

HEMORRHAGE 

Hemorrhage  of  sufficient  importance  to  demand  a 
doctor's  attention  usually  demands  ligation  of  the  bleed- 
ing vessel,  enlarging  the  cut  sufficiently  (generally  under 
cocaine  anesthesia  or  freezing)  to  permit  it  to  be  seized 
with  forceps. 

When  this  cannot  be  done  (for  one  reason  or  another) 
a  compress  soaked  in  a  solution  of  antipyrin  may  be 
applied  as  firmly  as  possible;  or  a  tight  packing  of  iodo- 
form  or  sublimated  gauze  may  be  put  in.  Constriction 
of  an  extremity  by  an  Esmarch  or  Martin  bandage  should 
not  be  continued  longer  than  two  and  one-half  hours. 
Bleeding  from  particular  organs  will  be  discussed  under 
the  respective  headings  devoted  to  them. 

Internal  Hemorrhage. — From  the  use  of  enemas 
of  hot  milk  remarkable  results  are  claimed  by  Solt.  He 
advises  introduction  by  means  of  a  piston  syringe;  the 
intermittent  flow  gives  better  results  than  a  constant 
stream  from  a  fountain  syringe.  By  this  means  it  is  said 
that  hemorrhages  from  the  uterus,  bladder,  stomach, 
lungs,  and  in  fact  from  every  part  of  the  body  have  been 
checked.  In  some  cases  more  approved  hemostatics 
had  been  used  for  hours  without  result,  and  the  milk 
was  immediately  successful.  At  least  a  quart  should  be 
given  at  once,  with  nothing  added  but  a  little  salt  to  make 
it  absorb  more  rapidly.  The  enema  should  be  repeated 
in  an  hour,  even  if  there  is  no  return  of  the  hemorrhage. 
Of  course  the  usual  local  measures  are  employed  at  the  same 
time,  when  the  source  of  bleeding  can  be  reached.  The 
method  of  its  action  is  not  certain,  but  milk  contains  a 


196  SURGICAL  THERAPEUTICS 

large  number  of  substances  which  are  recommended  as 
hemostatics — iron,  phosphoric  acid,  sulphuric  and  nitric 
acids,  but  above  all,  lime  salts.  The  enzymes  and  leu- 
cocytes also  tend  to  cause  an  increase  in  the  fibrin  fer- 
ment. The  milk  loses  its  hemostatic  power  if  it  is  given 
by  the  stomach.  But  while  one  is  experimenting  with 
milk  he  must  not  forget  that  atropine  is  one  of  our  best 
general  hemostatics. 

HEMORRHOIDS 

The  proper  treatment  of  piles  may  be  summed  up  in 
a  few  words.  External  tags  (old  piles)  may  be  snipped 
off  under  cocaine  or  ethyl-chloride  freezing.  A  large, 
recent,  external  pile  may  be  cut  around,  ligated  and 
removed.  Internal  hemorrhoids  demand  divulsion  of 
the  sphincter  ani  under  complete  anesthesia,  and  then 
removal  by  (i)  excision  and  sewing  up  of  the  cut  after 
ligation  of  vessels,  (2)  ligation  in  an  incision  made  around 
the  base  and  then  excision,  or  (3)  use  of  a  clamp  and 
cautery.  The  last-named  gives  least  pain  and  most 
satisfactory  results  if  properly  done. 

When  the  patient  will  not  consent  to  operative  meas- 
ures the  injection  method  may  be  used,  treating  by  inject- 
ing only  one  pile  at  one  sitting,  introducing  15  to  20  drops 
of  pure  phenol,  or  equal  parts  phenol  and  fluid  extract 
of  ergot,  the  fluid  to  be  thrown  exactly  into  the  center 
of  the  pile-mass  as  otherwise  sloughing  may  be  induced. 

If  neither  plan  of  treatment  will  be  permitted,  pal- 
liative measures  alone  can  be  practised.  These  are  (i) 
astringent  injections  (tannic  acid  one  gram — 15  grains — 
to  the  pint  of  water,  or  twice  that  strength  of  alum,  or 
one  in  eight  of  tincture  of  hamamelis)  especially  when 
there  is  bleeding  from  internal  hemorrhoids.  (2)  Use  of 
astringent  washes,  like  witchhazel  or  liquor  antisepticus, 
U.  S.  P.  Very  hot  water  frequently  applied  is  very 


HEMORRHOIDS  197 

comforting.  If  the  pile  can  be  well  greased  and  pushed 
above  the  sphincter  immediate  comfort  will  result  if  it 
be  one  which  originated  above  the  sphincter  and  came 
down  with  bowel-movement,  as  is  often  the  case.  (3) 
Application  of  astringent  ointments  like 

Gallic  acid 0.5  (grs.  8       ) 

Extract  of  belladonna 0.3  (grs.  5       ) 

Cocaine  hydrochloride o.i  (grs.  i  1-2) 

Lanolin 16.0  (oz.       1-2) 

Apply  three  or  four  times  a  day. 
Aesculin  in  Hemorrhoids. — When  a  patient  will 
not  submit  to  operation  for  piles,  suppositories  of  tannic 
acid  may  be  ordered  or  an  ointment  prescribed;  but  better 
results  may  often  be  obtained  from  laxatives  (cascara 
preparations  are  much  better  than  anything  contain- 
ing aloes — a  drug  which  aggravates  hemorrhoids  and 
often  causes  much  anal  irritation  and  itching)  and  from 
aesculin.  This  glucoside  is  the  active  principle  of  the 
horse-chestnut,  a  bitter  tonic  and  stimulant  to  the  cir- 
culation, having  especial  tendency  to  overcome  stasis 
in  the  portal  circulation — including  the  hemorrhoidal 
veins.  It  is  obtainable  in  granule  form,  each  granule 
containing  i  milligram  (gr.  1-67).  From  three  to  five 
of  these  granules  may  be  ordered  administered  every 
two  hours  uutil  the  burning  and  itching  are  decidedly 
relieved. 

Hemorrhoids  and  Rectal  Fissure. — Altogether  too 
many  people  are  allowed  to  suffer  from  hemorrhoids 
and  anal  fissure  without  examination.  It  is  so  easy  to 
give  a  little  "pile-ointment"  or  a  few  suppositories;  it 
is  so  "nasty"  to  make  a  careful  examination.  And  so — 
patients  either  suffer  for  years  or  drift  into  the  hands  of 
the  "pile-specialists."  Yet  a  rectal  speculum  costs  but 
$2.00  and  a  Paquelin  cautery  only  $8.00;  these  with  a 
little  chloroform  and  some  common-sense  may  be  made 


108  SURGICAL  THERAPEUTICS 

to  cure  these  conditions — unless  excessively  bad — to 
the  unbounded  relief  of  the  patient  and  the  great  credit 
of  the  family  doctor.  Less  ointments,  more  fire,  should 
be  the  rule. 

Hemorrhoids:  Treatment  after  Operation. — 
When  piles  have  been  removed  either  by  ligature  or 
clamp  and  cautery,  the  sphincter  having  always  been  forcibly 
dilated  prior  to  operation,  it  is  imperative  that  the  rectal 
packing  extend  very  high  into  the  gut  and  that  it  be  tamped 
in  very  tightly.  This  pack  is,  preferably,  iodoform  gauze, 
though  dry  bichloride  gauze  will  do.  Over  this  a  pad 
of  absorbent  gauze  or  cotton  is  placed,  held  by  a  T-bandage 
applied  tightly.  The  outside  gauze  may  be  changed  every 
day,  if  desired,  b.ut  the  packing  must  not  be  disturbed 
for  from  four  to  six  days,  during  which  time  peristalsis  is 
to  be  controlled  by  opium  or  morphine  by  the  mouth. 
When  accumulation  of  gas  becomes  distressing,  however, 
the  plug  must  be  removed  and  the  bowels  permitted  to 
move.  In  many  cases  it  is  best  to  give  a  good  saline  laxa- 
tive and  let  the  bowel-movement  force  the  packing  out — 
assisted  by  the  patient's  own  fingers — as  this  will  cause 
far  less  suffering  than  if  removed  by  doctor  or  nurse.  If 
it  be  left  until  the  fifth  or  sixth  day,  however,  it  usually 
slips  out  without  much  discomfort.  An  enema  should 
be  taken  immediately  after  the  first  bowel-movement, 
and  daily  thereafter  for  a  week. 

Inflamed  and  Protruding  Piles. — The  following 
combination  is  recommended  in  the  treatment  of  inflamed 
and  protruding  piles: 

Cocaine  hydrochloride 0.17  (grs.    2  1-2) 

Sol.  adrenalin  chloride  (i  :  iooo)..2.oo  (dr.         1-2) 

Bismuth  subnitrate .0.67  (grs.  10       ) 

Petrolatum  (liquid) 30.00  (oz.      i       ) 

M.  Ft.  unguentum.  Sig. :  Bathe  the  parts  in  cold 
water  and  apply  the  ointment  after  each  stool. 


HEPATIC  COLIC  199 

Injection  of  Hemorrhoids. — An  injection  highly 
praised  for  cure  of  a  single  pile,  when  a  patient  will  not 
submit  to  operation,  consists  of: 

Tannic  acid 1.5  (grs.  20) 

Phenol  8.0  (drs.    2) 

Glycerin 8.0  (drs.    2) 

Water 16.0  (oz.  1-2) 

This  makes  a  25-percent  solution  of  phenol,  which,  plus 
the  astringent  tannin,  quickly  coagulates  the  blood,  when 
thrown  into  the  pile.  It  is  so  prompt  in  its  solidification 
of  the  hemorrhoid  that  the  point  where  the  hypodermic 
needle  entered  often  remains  open.  As  much  as  a  syringe- 
ful  may  be  injected  (through  a  rectal  speculum)  into  a 
large  hemorrhoid.  There  is  not  much  pain  or  discom- 
fort after  its  use;  and  the  pile  is  usually  cured.  Only  one 
should  be  injected  at  one  sitting. 

Nitric  Acid  for  Piles. — For  many  years  nitric 
acid  has  held  high  favor  in  the  management  of  bleeding 
hemorrhoids.  Internal  piles  are  treated  by  the  appli- 
cation of  a  drop  or  two  (through  a  speculum)  to  the  hemor- 
rhoidal  mass;  not  to  the  whole  surface,  but  simply  to 
one  or  two  points.  It  is  not  painful.  Two  or  three  appli- 
cations to  the  dilated  vessels  are  sufficient.  For  bleed- 
ing piles  a  dram  of  the  dilute  acid  is  added  to  half  a  pint 
of  water  and  applied  with  a  little  absorbent  cotton.  Quite 
promptly  the  bleeding  ceases,  the  protruding  mass  shrinks 
from  constriction  of  the  vessels  and  the  heavy,  dull,  weary- 
ing discomfort  subsides,  even  though  the  pile-tumor 
cannot  be  returned  within  the  sphincter. 

HEPATIC  COLIC 

Colic  due  to  the  passage  of  a  small  stone  down  the 
cystic  and  common  ducts  or  to  the  attempted  entrance 
of  a  large  stone  into  the  cystic  duct  is  one  of  the  most 


200  SURGICAL  THERAPEUTICS 

fearful  of  all  pains.  For  its  relief  there  is  nothing  so 
satisfactory  as  the  injection  of  one  tablet  of 

Morphine   hydrobromide 0.02    (gr.  1-4  ) 

Hyoscine  hydrobromide o.ooi  (gr.  1-67) 

Cactin    o.ooi  (gr.  1-67) 

or  the  hyoscine-morphine-cactin  tablet  [H-M-C,  Abbott] 
now  on  the  market.  It  may  be  repeated  in  an  hour  and 
a  third  dose  may  be  given  two  hours  later  if  necessary. 
It  does  not  give  so  great  relief  when  taken  by  mouth. 
If  instant  relief  is  demanded  a  little  chloroform  may  be 
given  by  inhalation  until  the  opiate  has  time  to  take  effect. 
Hot  fomentations  of  turpentine  to  the  abdomen  over  the 
region  of  the  gall-tract  may  afford  some  comfort  to  the 
patient;  but  it  must  not  be  applied  by  hard  rubbing,  since 
manipulation  might  rupture  a  distended  gall-bladder. 
It  is  a  common  custom,  nowadays,  to  give  large  doses 
of  olive  oil.  This  is  not  objectionable  if  it  does  not  cause 
vomiting  (anything  which  produces  emesis  is  dangerous),  as 
it  relaxes  the  bowels  and  possibly  helps  the  passage  of 
small  calculi.  The  lumps  of  "human  soap"  resultant 
from  action  of  the  intestine  upon  the  oil  must  not  be  mis- 
taken for  gallstones,  which  they  closely  resemble.  Half 
a  pint  of  the  oil  may  be  given  within  two  or  three  hours. 
After  the  attack,  to  prevent  recurrence,  an  outdoor  life 
should  be  ordered,  with  salines  at  night,  and  a  good, 
nutritious  diet  devoid  of  much  fat,  without  wines  or  beer, 
should  be  enjoined;  too  much  emphasis  cannot  be  laid 
upon  the  necessity  for  careful,  thorough  mastication  of 
the  food,  by  which  the  quantity  taken  may  be  reduced 
fully  one-half.  One  should  not  be  hasty  about  urging 
operation,  because  after  relief  of  one  paroxysm  the  patient 
may  carry  the  stone  for  many  years  without  any  discom- 
fort whatsoever;  but  if  the  attacks  return  again  and  again 
nothing  will  afford  relief  but  removal.  If  the  gall-bladder 
be  badly  affected  it  also  may  be  removed. 


HEPATITIS  201 

HEPATITIS 

Inflammation  of  the  liver  is  not  a  surgical  affection 
save  when  it  ends  in  suppuration.  But  as  the  province 
of  the  surgeon  is  to  prevent  as  well  as  cure  suppurative 
conditions  the  proper  treatment  of  hepatitis  may  well  be 
considered  here.  By  the  term  hepatitis  is  meant  the  true, 
acute,  inflammatory  process  which  results  from  the  intro- 
duction of  pathogenic  microorganisms  through  wound 
or  otherwise  and  not  that  condition  generally  called 
"chronic  hepatitis"  which  is  not  an  inflammation  at  all. 

The  first  essential  is  to  secure  perfect  rest  in  bed,  to 
which  end  the  application  of  a  huge  mustard-plaster 
aids;  or  hot  cloths  may  be  ordered  for  the  right  side, 
to  minimize  the  pain.  Calomel  in  two  centigram  doses 
(gr.  1-6)  every  hour  until  free  purgation  results  is  an 
almost  universal  treatment  now,  and  it  may  well  be  fol- 
lowed by  effervescing  saline  laxative  (Abbott's).  To  check 
the  fever  the  best  drug  is  aconitine  in  doses  of  two  mil- 
ligrams every  hour  until  the  desired  result  is  obtained 
and  then  as  often  as  necessary  to  keep  the  temperature 
down.  Active  kidney  secretion  must  be  promoted  by 
the  use  of  potassium  citrate,  one  to  four  grams.  (15  to  60 
grains),  three  or  four  times  a  day.  If  the  pain  is  severe 
half -decigram  doses  of  codeine  sulphate  (1-2  to  i  grain) 
every  three  or  four  hours  may  be  given  by  mouth. 

If  in  spite  of  this  treatment  the  trouble  goes  on  to 
the  formation  of  an  abscess,  as  indicated  by  rigors,  sub- 
normal temperature,  night-sweats,  hectic  fever,  etc., 
the  pus  must  be  liberated  as  soon  as  possible.  The  liver 
must  be  exposed  over  a  considerable  area,  by  cutting 
away  the  ribs,  usually;  and  if  adhesions  have  not  formed 
between  Glisson's  capsule  and  the  parietal  peritoneum, 
gauze  must  be  packed  between  the  liver  and  belly-wall 
in  every  direction  until  the  adhesion  does  take  place.  In 


202  SURGICAL  THERAPEUTICS 

forty-eight  hours,  without  removal  of  the  gauze,  the  pus 
may  be  sought  by  use  of  an  exploring  needle  of  large  size 
thrust  in  various  directions  until  the  abscess  is  found;  it 
must  then  be  opened  by  free  incision,  wiped  out  with  gauze, 
thoroughly,  and  then  gently  packed  with  gauze  for  drain- 
age. It  should  not  be  washed  out  with  hydrogen  dioxide 
before  the  first  week  of  drainage.  Subsequently  it  is 
to  be  managed  as  any  other  huge  abscess  which  must 
heal  by  granulation  from  the  depths.  Dysentery  is 
likely  to  prove  troublesome  after  evacuation;  it  may  be 
controlled  by  use  of  opium,  camphor  and  acetate  of  lead, 
a  most  satisfying  prescription  being  half  a  decigram  of 
each  (3-4-grain)  in  a  capsule  every  three  or  four  hours. 

HERNIA 

It  is  said  that  one  in  every  eight  men  has  some  form 
of  hernia.  Yet  how  many  doctors  think  of  advising  an 
operation?  They  know  that  operation  is  perfectly  safe 
and  cure  almost  certain  (in  my  own  work — now  covering 
several  hundreds  of  cases — there  has  never  been  a  death 
and  less  than  five  per  cent  of  recurrences);  yet  they  pre- 
fer merely  to  fit  a  truss  rather  than  urge  radical  cure. 
It  is  hard  indeed  to  account  for  their  indifference  to  the 
future  welfare  of  their  rupture  cases — probably  timidity 
and  a  feeling  engendered  by  the  failures  of  a  few  years 
ago  that  cure  is  not  sure.  It  is  the  duty  of  every  doctor 
to  explain  the  advantages  of  operative  treatment  to  every 
patient  afflicted  by  hernia  and  only  permit  the  wearing 
of  a  truss  under  serious  protest. 

One  of  the  instances  in  which  scopolamine-morphine 
anesthesia  is  particularly  indicated  is  reduction  of  strangu- 
lated hernia.  The  relaxation  is  almost  as  complete  as 
in  chloroform  narcosis  and  there  is  not  the  vomiting  which 
usually  follows  general  anesthesia  and  which  sometimes 
cannot  be  distinguished  from  early  stercoraceous  emesis. 


HERNIA  203 

Diaphragmatic  Hernia. — The  colon  or  a  part  of  the 
stomach  may  crowd  through  a  hiatus  in  the  diaphragmatic 
muscular  tissue,  carrying  the  parietal  peritoneum  and  the 
pleura  with  it  as  a  sac — forming  a  diaphragmatic  hernia. 
The  only  possible  treatment  is  an  abdominal  section  close 
to  the  ensiform,  withdrawal  of  the  hernial  contents  and 
closure  of  the  hole  with  2o-day  chromicized  catgut.  Recur- 
rence may  be  anticipated. 

Hernia  Cerebri. — Hernia  cerebri  is  due  to  infection 
of  the  brain  near  the  opening  through  which  the  inflamed 
tissue  protrudes.  Therefore  the  treatment  must  be  largely 
antiseptic,  but  antiseptic  in  a  mild  way,  since  active  agents 
like  bichloride  increase  the  congestion.  Probably  the  best 
treatment  consists  in  enlarging  the  opening,  if  possible, 
for  a  half  inch  on  every  side  of  the  extruding  brain-mass 
and  dusting  the  wound  and  brain  with  iodoform,  applying 
antiseptic  gauze  over  it  from  time  to  time.  Secretions 
should  be  gently  wiped,  not  washed,  away.  If  abscess 
forms  (not  common)  it  must  be  opened  and  drained. 
Great  patience  must  be  exercised  as  the  hernia  sometimes 
persists  for  weeks  and  then  gradually  recedes.  If  persistent, 
the  brain  finally  becomes  a  mass  of  granulation-tissue  which 
so  utterly  destroys  the  cortex,  that  the  whole  thing  may  as 
well  be  removed  by  burning  with  Paquelin  cautery. 

Hernia  in  Children. — Hernias  in  children  are  most 
often  of  the  umbilical  and  inguinal  variety;  though  there 
are  many  cases  of  femoral  hernia  reported  this  condition 
is  comparatively  rare  before  the  age  of  puberty.  Those 
who  have  much  to  do  with  the  surgical  treatment  of  chil- 
dren are  struck  by  the  number  of  cases  of  hydrocele  of  the 
cord  which  have  been  treated  as  though  this  condition 
were  hernia.  This  perhaps  is  the  only  condition,  certainly 
the  only  condition  in  infancy,  which  is  likely  to  lead  to 
error  in  diagnosis.  Umbilical  hernia  of  infancy  rarely  calls 
for  operation,  being  readily  cured  by  pressure,  best  applied 


204  SURGICAL  THERAPEUTICS 

through  the  medium  of  a  pad  with  a  flat  surface  secured 
in  position  by  adhesive  straps.  As  to  the  treatment  of 
inguinal  hernias,  the  general  opinion  of  the  profession  is 
undergoing  a  change.  It  was  formerly  held  that  the  great 
majority  of  such  ruptures  could  be  cured,  and  permanently 
cured,  by  a  properly  fitting  truss.  Some  cures  certainly 
have  thus  been  effected.  As  to  whether  or  not  this  cure  is 
a  permanent  one,  some  are  not  decided;  others  contend  that 
the  hernia  will  come  down  again  when  the  boy  reaches 
manhood,  with  its  strains.  Certain  it  is  that  operation  is 
safe,  and  is  almost  sure  to  give  perfect  and  permanent 
cure  if  properly  performed. 

Inguinal  Hernia  in  Yotmg  Children. — This  is  a 
condition  which  should  not  be  neglected.  As  a  rule  it  is 
best,  before  resorting  to  operation,  to  try  to  cure  the  rup- 
ture by  means  of  a  truss  or  other  mechanical  measures,  with 
the  following  exceptions  to  the  general  rule:  Operate  (i)  in 
case  of  strangulation,  or  where  strangulation  has  been 
reduced  by  taxis;  (2)  upon  all  cases  not  controlled  by  truss; 
(3)  when  truss- wearing  causes  pain;  (4)  when  the  patient 
cannot  be-observed  regularly;  (5)  in  cases  associated  with 
reducible  hydrocele,  or  fluid  in  the  hernial  sac.  But  opera- 
tive treatment  being  perfectly  safe,  and  absolutely  sure 
to  effect  a  cure  if  properly  done,  every  patient  should  be 
subjected  to  the  Bassini  method,  which  deservedly  occupies 
first  place  in  the  treatment  of  inguinal  hernia,  for  it  deals 
thoroughly  with  the  sac  and  with  the  canal.  There  are 
two  points  in  this  operation  deserving  of  special  emphasis: 
First,  in  splitting  the  aponeurosis  of  the  external  oblique, 
the  division  should  be  made  in  the  cleavage  line,  as  high 
above  Poupart's  ligament  as  possible;  if  the  division  is 
made  directly  over  the  inguinal  canal,  the  lower  flap  of 
aponeurosis  is  so  short  that  it  is  difficult  to  put  in  the 
second  row  of  sutures  without  tension  and  subsequent 
danger  of  sloughing  and  splitting.  'The  longer  flap  obviates 


HERNIA  205 

this  danger  and  gives  a  stronger  wall.  The  other  point  is 
this:  Lloyd  has  demonstrated  that  in  recurrences  the 
relapse  is  at  the  lower  end  of  the  wound,  and  the  rupture 
is  of  the  direct  type;  therefore,  it  is  of  the  greatest  import- 
ance accurately  to  coapt  the  internal  oblique  and  trans- 
versalis  muscle  to  Poupart's  ligament  at  the  lower  end  of 
the  wound.  Children  bear  surgical  work  remarkably  well, 
and  there  is  no  major  operation  in  surgery  attended  with 
as  little  shock  and  giving  as  satisfactory  results,  as  the 
operation  for  the  radical  cure  of  inguinal  hernia.  The 
curability  of  rupture  in  early  childhood  by  operation  is  a 
settled  question.  The  safety  of  the  method  is  generally 
acknowledged.  The  only  question  then  is,  shall  we  operate 
or  shall  we  apply  a  truss  ?  The  former  plan  requires  about 
two  weeks  to  effect  a  cure,  the  latter  requires  two  or  more 
years,  and  is  far  more  uncertain. 

Injection. — Schwalbe's  method  of  treatment  consists 
in  reducing  the  hernia  and  then  injecting  pure  alcohol 
around  the  sac  on  every  side.  The  resulting  irritation  of 
serous  surfaces  and  long-continued  induration  sometimes 
causes  obliteration  of  the  sac  in  favorable  cases. 

Local  Anesthesia  in  Operations  for  Hernia.. — 
Bodine  claims  that  by  proper  cocainization  this  operation 
can  be  rendered  absolutely  painless.  It  is  necessary  to 
employ  only  a  one-fifth  of  one-percent  solution  and  never 
inject  more  than  one-half  grain  of  cocaine,  so  that  serious 
symptoms  of  poisoning  never  occur.  This  solution  is 
used  for  skin  infiltration  and  cocainizing  the  nerve  trunks; 
for  the  deeper  tissues  a  solution  half  this  strength  is  used. 
The  solution  should  always  be  fresh,  as  aqueous  solutions 
of  cocaine  are  certain  to  deteriorate.  The  method  is  as 
follows:  The  skin  is  first  infiltrated,  the  proper  depth  to 
which  the  needle  is  penetrated  into  the  skin  being  such 
that  the  needle  is  always  visible  just  beneath  the  surface. 
The  skin  having  been  anesthetized  the  needle  is  plunged 


206  SURGICAL  THERAPEUTICS 

through  the  skin  and  the  tissues  around  the  external  ring 
are  infiltrated.  The  skin  incision  down  to  the  aponeurosij 
is  then  made.  If  there  is  much  fat  this  is  also  infiltrated 
with  a  i  in  1000  solution.  The  ilioinguinal  nerve  is  then 
exposed  and  is  cocainized  at  the  higher  point.  The  dis- 
section can  be  carried  out  further  into  the  external  ring; 
the  two  flaps  of  fascia  are  retracted,  exposing  the  shelving 
border  of  Poupart's  ligament  externally  and  the  conjoined 
tendon  on  the  inner  side.  The  iliohypogastric  nerve  can 
be  searched  for,  and  if  found,  cocainized;  which  will 
materially  assist  in  securing  painlessness  of  the  operation. 
If  it  is  not  found  the  margins  of  the  internal  ring  and  the 
adjacent  part  of  the  conjoined  tendon  are  injected  with  a 
one-tenth  of  one-percent  solution.  Along  the  center  line 
of  the  long  axis  of  the  protrusion  a  line  of  infiltration  with 
the  same  solution  is  made.  The  sac  is  then  opened  and 
the  contents  dealt  with  as  occasion  requires;  there  being 
practically  no  sensation  in  the  omentum  and  intestines 
no  application  of  cocaine  to  them  is  necessary.  The  neck 
of  the  sac  is  infiltrated,  dissected  away  from  the  under- 
lying cord,  ligated  and  amputated.  The  genitocrural  nerve 
is  sought  for,  and  if  it  is  found  and  cocainized  the  operation 
can  be  completed  in  any  manner  the  operator  prefers 
without  additional  cocaine.  If  the  nerve  is  not  found,  the 
operation  must  be  completed  as  speedily  as  possible,  as 
there  will  quickly  be  a  return  of  sensation.  The  ultimate 
results  are  as  good  as  under  general  anesthesia. 

Redaction  of  Hernia. — When  the  contents  of  a  her- 
nial  sac,  previously  reducible,  cannot  be  returned  to  the 
abdomen  the  patient  should  be  given,  hypodermically,  1-4 
grain  of  morphine  and  1-250  of  hyoscyamine,  or  even  the 
latter  alone,  repeating  if  necessary.  In  half  an  hour  a 
good  dose  of  strychnine  should  be  injected  if  the  pulse  is 
weak.  Then  with  the  patient  upon  his  back,  a  pillow 
under  the  hips  and  knees  drawn  up  (and  supported  by 


HICCOUGH  AFTER  OPERATION  207 

some  one)  to  relax  all  muscles  a  few  drops  of  chloroform 
may  be  given  by  inhalation;  relaxation  will  be  complete 
in  a  few  minutes  and  the  hernia  may  spontaneously  dis- 
appear. If  not,  gentle  taxis  may  be  instituted;  but  no  force 
must  be  used  and  efforts  at  reduction  should  not  be  con- 
tinued more  than  fifteen  minutes.  The  H-M-C  combina- 
tion seems  admirably  adapted  for  these  cases.  If  the 
trouble  cannot  be  relieved  in  that  time  operation  is  needed, 
and  soon. 

Strychnine  in  Strangulated  Hernia. — Often  the 
nervous  depression  in  strangulated  hernia  is  alarmingly 
apparent  when  the  surgeon  reaches  the  patient's  bedside; 
indeed  it  is  so  great  that  strong  men  die  from  the  shock 
of  what,  under  other  conditions,  would  be  a  trivial  operation. 
When  this  condition  is  present,  the  first  thing  to  be  done 
after  ascertaining  the  nature  of  the  trouble  is  to  inject 
four  milligrams  (about  1-15  grain)  of  strychnine  sulphate. 
In  a  few  minutes  a  dose  of  the  hyoscine-morphine-cactin 
anesthetic  may  be  injected,  and  by  the  time  everything  is 
ready  for  operation  (which  may  often  be  done  under  cocaine) 
the  general  condition  of  the  patient  will  be  much  improved. 

HICCOUGH  AFTER  OPERATION 

Occasionally  a  persistent  hiccough  occurs  some  hours 
after  injury  or  serious  operation  and  becomes  quite  dis- 
tressing to  the  patient.  Possibly  the  best  thing  to  control 
it,  after  application  to  the  throat  of  clothes  wrung  out  of 
ice-water  has  failed,  is  "Hoffmann's  anodyne,"  the  spiritus 
setheris  compositus  of  the  U.  S.  P.  It  is  composed  of 
ether,  alcohol  and  heavy  oil  of  wine,  hence  is  a  stimulant 
of  almost  instant  action,  yet  prolonged  as  well;  the  ether 
is  taken  up  immediately,  the  alcohol  somewhat  later  and 
the  oil  of  wine  quite  a  time  afterward.  The  dose  is  one  to 
two  teaspoonfuls  every  hour  until  relieved.  Sometimes  a 
capsule  of  camphor  with  musk  arrests  hiccough  which  has 


208  SURGICAL  THERAPEUTICS 

resisted  all  other  medication;  but  pure  musk  is  very  hard 
to  get  and  is  of  great  cost. 

HIP-JOINT  DISEASE 

Coxalgia. — Technically  "pain  in  the  hip-joint";  often 
employed,  incorrectly,  by  the  older  writers  as  ynonymous 
with  "hip-joint  disease". 

Coxarthrocace. — Fungoid  inflammation  of  the  hip- 
joint  is  a  form  of  tuberculosis.  (See  "Tuberculosis  of 
Joints".) 

Coxitis. — Inflammation  of  the  hip-joint  does  not  differ 
from  that  of  any  other  joint  (see  "Arthritis")  when  o" 
any  origin  other  than  tuberculosis. 

HYDROCELE 

All  things  considered,  it  is  best  to  advise  excision  in 
most  cases  of  hydrocele.  Plastic  methods  (injection  of 
some  irritating  fluid  into  the  almost  emptied  sac)  are  not 
without  danger  and  frequently  fail,  though  95-percent 
carbolic  acid,  one  dram,  is  generally  regarded  as  harmless 
and  often  cures.  But  removal  of  the  sac,  save  enough  to 
cover  the  testicle,  is  so  perfectly  safe  in  clean  hands — and 
so  sure — that  one  should  not  hesitate  to  insist  upon  it  as 
a  method  of  choice. 

Injection  of  Hydrocele. — When  a  patient  will  not 
submit  to  the  simple,  safe  (in  aseptic  hands)  operation  for 
hydrocele  the  injection  method  may  be  tried.  The  best 
fluid  is  tincture  of  iodine  in  full  strength.  Some  prefer 
half  iodine  tincture  and  half  pure  phenol  (carbolic  acid). 
The  scrotum  is  thoroughly  scrubbed  and  dried,  washed 
with  ether  and  rinsed  with  6 5 -percent  alcohol;  then 
surrounded  with  a  sterile  towel,  preferably  taken  from  the 
boiler  in  which  the  trocar,  canula  and  hypodermic  syringe 
have  been  cooked.  The  trocar  and  canula  are  thrust  into 
the  sac,  avoiding  wounding  of  the  testicle,  and  the  fluid 


INCONTINENCE  OF  URINE  209 

allowed  to  escape.  Then  the  iodine  is  injected  either 
through  the  canula  or  with  the  hypodermic  needle  intro- 
duced through  the  same  hole.  The  sac  is  gently  rubbed 
so  as  to  distribute  the  iodine  and  the  external  opening  is 
closed  with  collodion.  The  inflammatory  reaction  is  not 
severe,  but  adhesion  is  sometimes  secured  between  the 
scrotal  and  the  testicular  layers  of  the  tunica  vaginalis,  with 
final  obliteration  of  the  sac. 

HYDROGEN  DIOXIDE 

Entirely  too  much  "peroxide"  is  used  hi  the  treatment 
of  suppurating  wounds  as  also  too  much  water  and  liquid 
antiseptics  of  all  sorts.  The  best  treatment  for  a  suppurat- 
ing, granulating  surface  is  merely  to  wipe  out,  gently,  with 
a  little  absorbent  cotton  or  gauze,  all .  surplus  secretion, 
exercising  great  care  not  to  disturb  the  delicate  granulations 
from  which  the  new  tissues  must  be  formed.  This  is 
particularly  applicable  to  pyothorax.  The  hydrogen  dioxide 
is  applicable  chiefly  to  those  suppurating  cavities  which 
do  not  drain  well  and  cannot  be  reached  with  the  cotton; 
and  also  to  those  suppurating  surfaces  which  show  a  ten- 
dency to  be  abnormally  slow  in  healing — here  the  irritating 
effect  being  just  sufficient  to  stimulate  the  sluggish  granula- 
tions. 

HYPODERMOCLYSIS:  CAUTION  IN 

When  injecting  large  quantities  of  normal  salt  solution 
beneath  the  skin  one  must  not  allow  too  much  fluid  to 
accumulate  at  one  area,  otherwise  necrosis  may  occur. 
It  is  best,  therefore,  to  shift  the  needle  to  various  parts 
not  by  swinging  it  from  side  to  side,  but  by  partly  with- 
drawing it  and  reinserting  it  to  another  area. 

INCONTINENCE  OF  URINE 

Women  occasionally  complain  that  they  pass  their 
urine  during  sleep.  To  such  patients  santonin  may  be 


210  SURGICAL  THERAPEUTICS 

given  in  doses  of  one  to  two  decigrams  (i  1-2  to  3  grains) 
three  times  daily.  It  often  checks  the  incontinence  after 
everything  else  has  been  used;  but  equally  often  it  does 
little  or  no  good.  Wetting  the  bed  by  little  girls  usually 
means  masturbation;  even  small  children,  mere  babies, 
practise  it;  in  which  cases  bromides  and  salicin  are 
advisable. 

INFECTIONS:    LOCAL 

The  treatment  of  these  troublesome  and  sometimes 
fatal  conditions  is  well  described  by  Weider,  of  Philadelphia. 
He  decries  the  folly  of  waiting  until  an  abscess  or  boil 
"points,"  thereby  increasing  the  opportunity  for  further 
infection  as  well  as  prolonging  the  most  painful  period  of 
the  entire  process,'  and  calls  attention  to  the  fact  that  any 
kind  of  a  poultice  can  do  nothing  but  accentuate  all  the 
undesirable  features  of  this  waiting. 

The  most  immediate  relief  of  pain,  the  quickest  process 
of  repair,  and  the  surest  preventive  against  secondary 
infection  are  secured  by  immediate  incision  over  the  point 
of  greatest  tenderness,  no  larger  than  necessary,  but  deep 
enough  to  allow  some  bleeding,  and  reaching  if  possible 
the  focus  of  infection.  The  wound  should  be  allowed  to 
bleed  as  freely  as  it  may,  and  then,  whether  or  not  pus  be 
found,  should  be  thoroughly  swabbed  out  with  phenol, 
lightly  packed  with  gauze,  and  a  wet  bichloride  dressing 
applied. 

The  patient  is  given  tablets  of  bichloride  of  mercury, 
instructed  how  to  make  a  i  in  1000  solution,  and  told  to 
use  it,  as  hot  as  he  can  bear  it,  three  times  a  day,  soaking 
the  affected  part  for  a  half  hour,  without  removing  the 
dressing.  In  the  majority  of  cases,  if  seen  in  time,  this 
treatment  is  abortive,  and  when  the  patient  appears  next 
day  all  symptoms  will  be  found  improved.  Should  the 
process,  however,  have  gone  on  to  actual  pus-accumulation 


INFECTIONS:     LOCAL  211 

or  to  necrosis,  the  symptoms  of  inflammation  will  have 
greatly  subsided  and  the  pain  have  either  disappeared  or 
be  markedly  lessened,  and  there  will  be  found  more  or  less 
discharge,  purulent  or  otherwise.  The  use  of  the  probe 
will  then  invariably  indicate  the  seat  of  infection,  either  as 
an  accumulation  of  pus  or  as  the  characteristic  "core." 
If  the  former,  it  should  be  freely  exposed,  using  scissors 
preferably;  if  the  latter,  it  should  be  removed  with  forceps, 
experience  having  pioved  the  use  of  the  curet  inadvisable 
in  these  cases.  Light  packing  and  the  repetition  of  the 
bichloride  dressing  is  then  resumed. 

Weider  closes  his  article  with  the  following  summary: 

"i.  Poultices,  socalled  antiphlogistics,  etc.,  are  use- 
less in  the  treatment  of  local  infections  and  do  harm  by 
causing  greater  destruction  of  tissue  and  delaying  proper 
remedies. 

"2.  Immediate  incision  over  the  point  of  greatest 
tenderness  should  always  be  practised,  followed  by  carbo- 
lization  of  the  wound  to  destroy  the  nidus  of  infection, 
and  then  a  wet  bichloride  dressing  should  be  applied. 

"3.  Free  incision  with  constant  wet  drainage  should 
be  the  rule  in  the  presence  of  pus. 

"4.  Dry  drainage,  especially  when  saturated  with 
coagulative  powders,  is  ineffectual  and  harmful  because  of 
the  'caking'  that  occurs  on  the  surface,  sealing  the 
cavity. 

"5.  Cases,  especially  with  drainage,  should  receive 
soakings  with  hot  bichloride  solutions  thrice  daily.  Hot 
salt  solution  or  water  may  be  used  if  the  bichloride  appears 
too  dangerous. 

"6.  Waxed  paper  should  not  be  used  over  wet  dress- 
ings, as  it  forms  them  into  moist  warm  poultices,  which 
are  objectionable. 

"7.  Never  curet  infections  primarily,  excepting  car- 
buncles, which  should  always  be  cureted  and  carbolized. 


212  SURGICAL  THERAPEUTICS 

"8.  Gauze  selvage,  when  soaked  in  bichloride  solution, 
makes  a  conveniently  handled  and  effectual  packing. 

"9.  Palmar  infections  of  the  fingers  and  hands  are 
more  serious  than  dorsal  infections. 

"  10.  In  incising  for  the  palmar  infections  of  the  fingers, 
continue  the  incision  until  pus  or  the  bone  is  reached,  and 
do  it  without  delay." 

INFLAMMATION:    BIER'S  METHOD  OF  CURE 

The  application  of  dry  heat  for  the  cure  of  inflammation 
(known  as  the  Bier  method)  has  been  given  extensive  trial 
recently. 

The  patients  selected  for  treatment  were  those  in  whom 
no  cure  could  be  expected  by  simply  placing  the  part  at 
rest;  as  a  rule  they  were  patients  in  whom  operative  pro- 
cedures were  indicated  but  who  declined.  The  cases  in- 
cluded acute  cellulitis  of  the  extremities,  bursitis,  phlegmon 
of  the  tendon-sheaths  of  the  hands,  lymphangitis,  furuncles, 
osteomyelitis,  tuberculous  gonitis,  gonorrheal  gonitis, 
erysipelas  of  the  extremities,  epididymitis,  etc.  The  best 
results  were  obtained  in  the  acute  inflammations.  The 
method  gives  better  functional  results,  it  lessens  the  duration 
of  treatment  and  relieves  pain.  Bier  especially  emphasizes 
the  alleviation  of  pain.  The  technic  of  the  method  is  not 
simple  and  easy;  one  needs  months  in  order  to  know  it 
thoroughly.  Experience  and  judgment  are  necessary  for 
success. 

INGROWING  NAILS:    TREATMENT  OF 

Free  application  of  dried  powdered  alum  is  sufficient 
to  cure  most  cases  of  ingrowing  nails  in  about  five  days. 
The  applications  are  never  painful  in  the  least,  and  the 
destruction  of  the  pathologic  tissue  results  in  the  formation 
of  a  hard,  resistant  and  non-sensitive  bed  for  the  nail, 
a  perfect  cure  for  the  ingrowing  tendency.  The  non- 


INTESTINAL  OBSTRUCTION  213 

toxicity  of  the  alum,  its  easy  application,  and  the  good 
results  render  it  the  treatment  of  choice  for  cases  in  which 
surgical  intervention  is  not  contemplated.  A  fomentation 
of  soap  and  water  is  applied  in  the  space  between  the  nail 
and  its  bed,  tamponing  with  cotton  to  keep  the  alum  in 
place,  and  repeating  the  application  daily.  The  suppura- 
tion rapidly  subsides,  and  pain  and  discomfort  are  relieved 
very  soon. 

A  very  good  way  to  treat  ingrowing  toe-nail  when  the 
patient  does  not  desire  an  operation  is  to  make  a  solution 
of  liquor  potassae,  U.  S.  P.,  in  water — two  drams  to  the 
ounce: 

Liquor  potassre 8.0 

Water 32.0 

and  saturate  a  small  bit  of  absorbent  cotton  with  this. 
The  cotton  is  to  be  pressed  gently  in  between  the  upper 
surface  of  the  nail  and  the  mass  of  tender  granulation- 
tissue.  The  alkali  soon  permeates  the  substance  of  the 
nail  without  irritating  the  sore;  but  the  cotton  must  be  kept 
constantly  moist  to  do  the  work  well.  The  softened  part 
of  the  nail  is  to  be  carefully  wiped  off  every  morning.  In 
a  few  days  the  nail  will  have  become  so  thin  and  soft  that 
it  can  be  cut  away  without  pain.  The  applications  must, 
however,  be  continued  until  all  granulations  disappear 
and  healing  is  well  under  way. 

INTESTINAL    OBSTRUCTION:     TREATMENT 
AFTER 

It  is  important  that  the  patient  be  disturbed  as  little  as 
possible,  yet  an  enema  is  a  good  thing  to  start  the  peris- 
taltic wave  downward  soon  after  the  bowel  has  been  opened, 
early  and  thorough  evacuation  being  essential  to  recovery, 
for  retention  of  the  poison  in  the  intestinal  tract  is  as  dan- 
gerous as  the  obstruction  which  caused  the  toxic  agents 
to  form.  Thirst  is,  therefore,  to  be  quenched  by  small 


214  SURGICAL  THERAPEUTICS 

sips  cf  iced,  effervescent  solution  of  citrate  of  magnesia; 
but  little  water  ought  to  be  given  by  mouth  during  the 
first  twenty-four  hours.  Large  enemas  of  warm,  slightly 
salt,  water  may  be  given  with  advantage  every  six  hours. 
Perfect  quietude  is  imperative — anxious  friends  must  be 
driven  out  and  the  patient  made  to  sleep  if  possible.  The 
first  few  hours  after  relief  of  intestinal  obstruction  are 
critical  ones,  and  too  great  care  cannot  be  exercised  to  se- 
cure perfect  tranquillity  for  the  patient.  No  matter  how 
much  complaint  may  be  made  of  pain,  morphine  must  not 
be  given — it  increases  the  danger  of  paresis  of  gut — almost 
always  an  exceedingly  serious  menace  to  life.  No  food 
should  be  given  by  mouth  until  more  than  forty-eight  hours 
have  elapsed,  but  a  few  nutrient  enemata  are  advisable 
if  the  patient  be  weak  or  complains  of  hunger.  Liquid 
diet  for  the  next  two  days  is  to  be  ordered. 

-.INTUSSUSCEPTION 

Nothing  but  operative  treatment  is  to  be  advised 
in  these  cases;  but  when  the  relatives  will  not  consent  to 
immediate  abdominal  section,  the  surgeon  may  still  do 
something  while  waiting.  But,  first  of  all,  he  should  freely 
explain  that  early  surgical  interference  is  indicated  in  order 
to  free  the  bowel  from  a  position  which  threatens  to  render 
it  necrotic  by  disturbance  of  the  mesenteric  circulation; 
this  nutritional  disturbance  of  the  bowel,  due  to  occlusion 
of  the  mesenteric  vessels,  must  be  relieved  as  soon  as  pos- 
sible, before  the  infection  of  the  peritoneal  cavity  promptly 
annihilates  the  results  of  the  operation.  But,  before  urging 
operation,  the  doctor  must  be  pretty  sure  of  his  diagnosis, 
since  it  is  humiliating  to  be  discharged  and  have  some 
"granny"  cure  the  patient  by  a  simple  enema. 

The  diagnosis  of  intussusception  is  easy.  It  depends 
upon  feeling  the  "lump"  of  the  invagination,  and  the 
passage  of  bloody  mucus  per  anum.  But  the  examination 


IODINE:     COLORLESS  215 

of  the  abdomen  should  invariably  be  conducted  under 
general  anesthesia.  The  most  important  therapeutic  indi- 
cation consists  in  the  reestablishment  of  the  obstructed 
mesenteric  circulation.  It  is  t )  be  then  explained  to  the 
friends  that  all  internal  therapeutic  measures  are  to  be 
rejected  as  inadequate  to  deal  with  the  condition  of  the 
incarcerated  segment  of  the  bowel.  As  soon  as  the  diag- 
nosis is  positive,  laparotomy  should  be  performed,  because 
this  form  of  treatment  alone  can  be  relied  upon  to  reestab- 
lish normal  conditions. 

Disinvagination  is  always  accomplished  by  gradually 
crowding  the  invaginatum  from  the  tip  through  the  entire 
sheath  of  the  invaginans,  using  the  thumb  and  index  finger 
of  both  hands.  After  the  invaginated  bowel-segment  has 
been  reduced,  bit  by  bit,  through  these  manipulations, 
cautious  traction  may  be  employed  for  the  purpose  of 
determining  that  the  surfaces  of  intussusceptum  and 
intussuscipiens  slip  smoothly  by  each  other.  It  is  a  serious 
mistake,  however,  to  attempt  the  reduction  of  the  invagina- 
tion  only  by  means  of  traction,  because  the  mechanical 
conditions  of  the  intussusception  are  not  recognized  in 
this  manipulation.  The  outcome  of  a  given  case  depends 
not  alone  upon  the  duration  of  the  intussusception,  but  also 
upon  the  degree  of  the  obstruction  of  the  mesenteric  circu- 
lation. 

Opiates  should  never  be  given;  nor  on  the  contrary, 
should  physic.  But  the  lower  bowel  should  be  washed 
out  repeatedly  with  warm  water  to  which  has  been  added 
a  little  soap  and  glycerin.  Then  the  anesthetic  is  admin- 
istered. If  the  diagnosis  is  then  sure  operation  should  be 
urged;  if  refused  it  is  far  better  to  withdraw  from  the  case. 

IODINE:    COLORLESS 

When  patients  object  to  the  discoloration  of  skin  pro- 
duced by  painting  with  tincture  of  iodine,  as  in  the  treat- 


216  SURGICAL  THERAPEUTICS 

ment  of  goiter,  it  is  very  easy  to  make  colorless  iodine, 
and  make  it  instantly,  without  waiting  a  minute  for  the 
change : 

Tincture  of  iodine 24.0    (drs.    7  ) 

Aqua  ammonia 6.0    (drs.    i  1-2    ) 

Carbolic  acid    6.0    (drs.  10  to  12) 

Shake  well  and  wait  just  a  moment  and  all  color  will  be 
gone.  The  therapeutic  value  is  not  seriously  affected.  It 
is  of  much  value  as  a  local  application  in  several  surgical 
conditions — notably  in  goiter;  but  care  must  be  used  not 
to  cause  blistering. 

IODOFORM 

Absorption. — Many  surgeons  use  iodoform  as  a  powder 
for  its  drying  and  antiseptic  properties  as  well  as  for 
injection  of  tuberculous  cavities  (joints,  etc.).  Some  pa- 
tients, notably  those  of  pink  skin  and  red  hair,  are  easily 
poisoned,  both  locally  and  systemically.  The  local  mani- 
festation is  a  deep  erythema,  and  sometimes  the  formation 
of  vesicles.  The  symptoms  of  absorption  are  (i)  thick 
coat  upon  the  tongue  with  metallic  taste;  (2)  slight  nausea 
with  loss  of  appetite  and,  later,  in  extreme  cases,  vomiting 
and  diarrhea;  (3)  increase  of  pulse  to  120  or  140  per  minute, 
with  irregularity  and  palpitation  in  severe  poisoning;  (4) 
delirium  with  hallucinations  or  melancholia.  As  these 
symptoms  are  much  like  those  of  staphylococcus  infection, 
great  uneasiness  may  be  felt  upon  their  appearance,  but 
discontinuance  of  the  iodoform  application  or  withdrawal 
of  the  iodoform-gauze  pack  from  the  vagina  (after  vaginal 
hysterectomy),  from  the  abdomen  (after  appendectomy  or 
pelvic  operations)  or  other  wound  will  generally  be  followed 
by  prompt  disappearance  of  the  symptoms;  but  rarely  they 
persist  for  days  or  weeks  and  fatal  results  have  been 
reported.  Gram  doses  of  sodium  bicarbonate  are  recom- 
mended as  an  antidote. 


IODOFORM  217 

lodoform  Injections  into  Joints. — There  can  be  no 
doubt  but  that  most  brilliant  results  are  obtainable  in  some 
cases  of  tuberculous  arthritis  and  synovitis  by  injection  of 
lo-percent  iodoform  emulsion.  But,  on  the  other  hand, 
most  deplorable  results  have  followed  its  use  by  incompetent 
or  careless  surgeons  as  well  as  physicians.  It  must  be 
borne  in  mind  that  iodoform  powder  itself  is  not  sterile 
nor  is  it  germicidal;  most  pyogenic  microorganisms  thrive 
in  an  emulsion  of  iodoform,  and  the  glycerin,  too,  is  apt 
to  be  infected.  So  the  iodoform  must  be  sterilized  by 
soaking  in  i  in  1000  bichloride  solution  for  24  hours,  then 
placed  upon  a  sterile  plate  and  the  water  evaporated.  The 
glycerin  is  boiled  and  poured  into  a  mortar  which,  with  its 
pestle,  has  just  been  taken  from  the  boiler  or  sterilizer. 
Then  the  iodoform  is  added  and  the  whole  thoroughly 
triturated  and  poured  into  a  wide-mouthed,  sterilized 
bottle.  From  this  the  iodoform  emulsion  is  drawn  out  by 
the  freshly  boiled  syringe  (the  glass  stopper  being  instantly 
returned  to  the  iodoform-container)  and  injection  made  by 
a  sterile  needle  thrust  through  the  properly  cleaned  skin. 

lodoform  Wax-Filling. — "\Yhen  large  amounts  of 
bone  are  necessarily  removed  (for  necrosis,  tuberculosis, 
etc.)  the  cavity  may  be  filled  by 

lodoform  powder   60.0 

Spermaceti 20.0 

Oil  of  sesame    20.0 

Mix  in  a  mortar  just  out  of  a  sterilizer  and  put  into 
a  sterile  (boiled)  jar.  This  remains  fluid  at  i32°F.  The 
cavity  in  the  bone  must  be  perfectly  clean  and  dry,  and 
every  part  of  the  cavity  must  be  permeated  by  the  mass; 
drainage  usually  is  not  necessary,  but  if  thought  advisable, 
can  be  made  by  the  insertion  of  a  few  strands  of  plain 
catgut.  While  this  filling  is  for  temporary  use  only,  being 
pushed  out  by  the  growth  of  new  tissue,  the  wound  some- 
times heals  by  first  intention  and  the  filling  is  absorbed 


218  SURGICAL  THERAPEUTICS 

in  time.  Though  a  foreign  substance,  it  is  well  borne  by 
the  tissues;  pulse  and  temperature  sometimes  increase, 
but  usually  for  only  two  or  three  days.  Symptoms  of  iodo- 
form  poisoning  are  rare.  This  method  gives  its  best  re- 
sults in  cases  of  chronic  circumscribed  osteomyelitis, 
chronic  tuberculous  osteomyelitis  and  the  acute  form 
attended  by  necrosis. 

JAUNDICE 

Phosphate  of  Sodium  in  Jaundice.— It  has  become 
a  common  thing  to  give  phosphate  of  sodium  in  gallstone 
disease  as  well  as  in  every  other  condition  in  which  jaundice 
is  a  prominent  symptom.  The  fact  is  that  it  is  useful 
chiefly  in  catarrhal  jaundice  and  that  its  good  effects  in 
that  trouble  are  due  to  its  cathartic  action  and  not  to  any 
specific  influence  on  the  disease.  It  is  quite  irritating  to 
some  stomachs — far  more  so  than  rochelle  salt  or  Abbott's 
saline  laxative,  which  ought  to  be  used  instead  of  the  more 
disagreeable  sodium  salt. 

JOINTS:    ACUTE  INFECTIONS  OF 

The  acute  infections  of  the  joints  are  few  in  number, 
but  of  great  importance.  They  have  been  enumerated  by 
Lovett  as  (a)  acute  osteomyelitis  of  the  articular  end  of 
one  of  the  long  bones,  involving  the  joint  secondarily; 
(b)  acute  suppurative  synovitis,  or  joint  abscess;  (c)  acute 
plastic  synovitis  leading  to  joint  obliteration;  (d)  acute 
serous  synovitis.  Tuberculous  and  chronic  joint  diseases 
are  not  considered  in  this  classification,  being  essentially 
of  a  chronic  character. 

Acute  Osteomyelitis  is  an  acute  suppurative  inflam- 
mation of  bone  due  to  infection  of  the  bone-marrow  by 
pyogenic  organisms.  The  treatment  of  such  cases  consists 
in  the  earliest  possible  free  drainage  of  the  joint,  with  care- 
ful search  for  the  infected  area  of  bone,  which  should  be 


JOINTS:     ACUTE  INFECTIONS  OF  219 

opened,  cureted  and  packed,  allowing  healing  to  occur 
under  strict  antiseptic  precautions,  in  order  to  prevent 
a  secondary  mixed  infection. 

Actfte  Serous  Synovitis. — Occurs  in  connection  with 
general  infectious  disease.  It  is  often  classed  under  the 
name  of  articular  rheumatism.  It  does  not  differ  clinically 
or  pathologically  from  what  is  generally  regarded  as  acute 
articular  rheumatism.  It  may  be  produced  experimentally 
by  the  injection  of  cultures  of  pyogenic  organisms. 
It  cannot  as  yet,  however,  be  regarded  as  a  specific  infec- 
tious disease.  Evidence  rather  tends  to  identify  it  as  "an 
attenuated  pyemia." 

Acute  infections  of  the  joints  of  undoubted  bacterial 
origin  occur  in  two  grades  of  severity  in  connection  with 
many  infections.  In  many  cases  the  source  of  infection  can 
not  be  established,  and  in  such  cases  it  is  important  to 
remember  that  the  function  of  the  tonsils  and  the  presence 
of  pyogenic  bacteria  in  the  mouth  are  a  ready  source  of 
infection.  That  acute  articular  rheumatism  is  an  infection 
seems  probable  from  bacterial  and  especially  from  clinical 
evidence;  but  this  has  not  as  yet  been  definitely  proved. 

Actfte  Strppurative  Synovitis,  or  joint  abscess, 
occurs  as  a  result  of  various  infective  organisms  and  appears 
in  infectious  diseases  of  a  wide  range,  such  as  cerebro- 
spinal  meningitis,  diphtheria,  dysentery,  erysipelas,  epi- 
demic parotitis,  glanders,  gonorrhea,  epidemic  influenza, 
measles,  pneumonia,  pertussis,  puerperal  fever,  pyemia, 
septicemia,  scarlet-fever,  smallpox,  tonsillitis,  typhus  fever, 
typhoid  fever,  after  the  use  of  sound  and  catheters,  and 
possibly  in  malaria.  The  treatment  consists  of  free  drain- 
age of  the  joint  as  soon  as  evidence  of  suppuration  can  be 
established. 

Ankylosis  of  Joints. — Union  of  the  bones  forming  a 
joint  may  be  (a)  fibrous  or  (b)  bony.  The  x-ray  will 
determine  which  is  present  in  case  of  doubt.  It  will  also 


220  SURGICAL  THERAPEUTICS 

reveal  "false"  ankylosis  which  is  due  to  mere  rigidity  of 
the  surrounding  parts. 

The  treatment  of  the  false  or  spurious,  as  well  as  of  the 
fibrous  or  ligamentous,  consists  in  forcibly  breaking  down 
all  adhesions  (under  chloroform)  and  the  persistent  use  of 
passive  motion.  A  stimulating  liniment  (chloroform  lini- 
ment is  pleasing)  may  be  given. 

Bony  ankylosis  cannot  be  cured.  If  the  joint  be  in  an 
awkward  position  the  bone  may  be  broken  and  allowed 
to  unite  in  a  better  one. 

Gonorrhea  of  Joints. — Socalled  "gonorrheal  rheu- 
matism" is  an  acute  infection  of  the  synovial  membrane 
by  the  gonococcus;  in  reality,  with  the  exception  of  the 
mild,  evanescent  cases  which  are  due  to  toxemia,  it  is 
truly  a  pyemic  condition.  The  gonococcus  directly  invades 
the  affected  tissue,  and  the  foci  are  located  either  in  the 
synovial  membranes,  constituting  an  arthritis,  or  they 
are  in  the  articular  ends  of  the  bones,  constituting  an 
osteoarthritis.  In  osteoarthritis  the  bone  focus  is  always 
primary,  and  is  never  caused  by  extension  of  the  inflam- 
mation from  the  interior  of  the  joint.  Hence,  a  gonor- 
rheal  arthritis  remains  an  arthritis  and  never  involves 
the  bones,  no  matter  how  long  it  exists  or  what  its  inten- 
sity. Gonorrheal  joint  disease  may  be  recurrent,  but 
never  chronic.  The  cases  which  have  been  called  chronic 
are  those  in  which  the  initial  acute  inflammation  has 
left  behind  bands  of  adhesion  or  other  structural  change  in 
the  synovial  membrane  in  arthritis,  and  bony  outgrowths, 
or  anyklosis,  in  osteoarthritis.  These  changes,  unless 
treated  mechanically,  or  by  operation,  are  permanent. 

The  treatment  during  the  acute  stage  must  be  on 
general  lines,  and  must  depend  upon  existing  conditions. 

The  treatment  of  deformity  must  be  based  upon  the 
sajne  principles  which  govern  the  treatment  of  all  deform- 
ities. Cases  that  are  treated  properly  during  the  acute 


JOINTS:     ACUTE  INFECTIONS  OF  221 

stage  will  usually  get  well  without  disability.  It  lies 
with  the  general  practitioner  and  the  genitourinary  sur- 
geon to  prevent  the  serious,  often  life-long,  disability 
which  sometimes  follows  in  the  train  of  a  gonorrheal 
joint  infection. 

Joint-Inflammation  (Arthritis). — Inflammation  of 
a  joint  may  follow  an  injury,  with  infection  of  the  joint 
by  germs  of  pus — even  the  bacillus  of  typhoid  fever 
(Eberth's  bacillus)  and  of  the  grippe  (Pfeiffer's  bacillus) 
may  cause  suppuration  in  the  joints,  conspicuously  the 
knee.  Such  infections  (with  pyogenic  bacteria)  alone 
constitute  true  arthritis. 

But  by  long  usage,  and  by  reason  of  modern  patholo- 
gists  having  failed  to  give  any  definite  substitute  for  the 
name,  certain  chronic  conditions  must  be  classed  under 
the  head  arthritis.  They  are  the  following: 

a.  Arthritis    fungosa. — Tuberculosis    of    the    joints, 
"scrofula"  or  "white  swelling"  of  the  old  writers. 

b.  Arthritis  deformans. — A  peculiar  affection  of  the 
joint  known  also  as  arthritis  pauperum,  chronic  rheuma- 
toid   arthritis,    osteoarthritis,    rheumatic    gout,    nodular 
rheumatism    and    arthritis    proliferans.     It    is    character- 
ized  by   an   overgrowth   of   the   articular   cartilages   and 
synovial   membranes   with   destruction   of   such  parts  of 
the  cartilage  as  are  subjected  to  pressure  within  the  joint, 
with   the   consequent   deformity.     It   is   most  often   seen 
in  advanced  life  but  sometimes  is  met  in  young  persons 
who  have  the  rheumatic  diathesis  to  a  marked  degree. 

c.  Arthritis   uritica. — Changes   in   the   joints   due  to 
gout.     The    calcareous,    gouty    deposits    or    concretions 
around  a  joint  frequently  create  quite  a  deformity,  but 
can  be  remedied  only  rarely,  e.  g.,  by  blistering  with  can- 
tharrides.     They  are  called  arthritoliths. 

These  various  conditions  are  of  surgical  interest 
chiefly  from  the  standpoint  of  differential  diagnosis; 


222  SURGICAL  THERAPEUTICS 

but  the  condition  hitherto  described  as  "fungous  arthritis" 
is  of  enormous  import  to  surgeons,  since  it  embraces  tuber- 
culosis of  the  joints  (which  see). 

Joints:  Secondary  Impotence  of. — As  a  result  of 
(a)  direct  injury,  (b)  prolonged  immobilization  and  (3) 
the  effect  upon  the  mind  of  the  patient,  permanent  impair- 
ment of  a  joint  may  follow  even  a  trifling  traumatism. 
Reflex  amyotrophy  of  articular  origin  also  should  have 
a  place  in  surgical  pathology,  as  it  explains  the  patho- 
genesis  of  many  articular  affections,  such  as  passive  dis- 
locations, painful  flat-foot,  genu  valgum  of  adults,  scoliosis 
and  others.  The  functional  impotence  is  sometimes 
secondary  to  spinal  lesions,  which  result  from  the  articu- 
lar trauma  and  consist  of  diminution  of  motor-cells  in 
the  anterior  horns.  Later,  the  nerves  to  the  joints  undergo 
partial  degeneration  and  muscle-fibres  atrophy.  Trophic 
centers  which  preside  over  the  nutrition  of  periarticular 
tissues  are  probably  involved  also.  Reaction  to  electric 
currents  serves  to  establish  prognosis.  Early  cases  are 
usually  curable,  chronic,  incurable.  In  the  incurable 
patients,  static  electricity  will  relieve  pain  and  spasm, 
faradization  being  contraindicated. 

Plastic,  or  Ankylosing  Synovitis. — In  this  an  acute 
or  severe  joint  inflammation  is  followed  by  a  partial  or 
complete  obliteration  of  the  joint,  without  suppuration;  it 
is  most  familiar  as  an  accompaniment  of  gonorrhea.  Little 
can  be  said,  however,  of  its  etiology  and  no  satisfactory 
treatment  has  been  formulated. 

Tuberculosis  of  Joints. — It  may  begin  in  either 
the  synovial  membrane  or  the  bony  structures  contiguous 
to  the  joint.  Immobilization  and  perfect  rest  some- 
times effect  a  cure.  When  recognized  early  (it  is  too 
often  mistaken  for  rheumatism)  injection  of  the  affected 
joint  with  lo-percent  iodoform  emulsion  will  quite  often 
cure.  The  iodoform  must  be  fresh;  the  glycerin  steril- 


KIDNEY  223 

ized  by  boiling.  The  glass  mortar  and  pestle  are  boiled 
'  twenty  minutes.  Then  one  part  iodoform  (say,  one  ounce) 
is  triturated  in  10  parts  of  the  glycerin  and  the  emulsion 
poured  into  a  sterilized  bottle  and  kept  tightly  corked; 
or  better,  put  in  a  fruit-jar  which  can  be  closed  perfectly. 
At  the  time  of  the  injection  the  skin  is  to  be  sterilized 
and  the  syringe  boiled.  About  one  ounce  of  the  emul- 
sion (well  shaken)  may  be  thrown  into  a  large  joint  like 
the  ankle  or  elbow.  Some  fever  may  result,  during  which 
the  joint  is  to  be  kept  quiet.  After  it  subsides,  together 
with  the  immediate  soreness,  the  joint  may  be  used  mod- 
erately. The  injection  may  be  repeated  in  three  or  four 
weeks  and  the  joint  put  in  plaster-of-paris  for  three  weeks. 
If  the  iodoform  treatment,  and  surgical  rest  do  not  cure 
in  a  few  months,  operative  treatment  is  usually  advisable, 
except  in  Pott's  disease  and  sometimes  in  tuberculosis 
of  the  hip-joint. 

Internally  the  treatment  is  essentially  tonic  and  sup- 
portive— practically  the  same  as  for  any  other  form  of 
tuberculosis. 

KIDNEY 

Alkalis  for  Stone  in  the  Kidney. — Before  resort- 
ing to  operative  measures  for  stone  in  the  kidney  it  is 
best  to  give  large  doses  of  potassium  citrate  for  two  or 
three  weeks,  unless  there  are  evidences  of  infection  by 
pyogenic  bacteria.  Patients  who  complain  of  much  pain 
in  the  back,  who  pass  bloody  urine,  and  even  those  who 
are  discharging  small  quantities  of  pus,  are  not  infre- 
quently entirely  relieved  by  this  course  of  treatment. 
The  explanation  is  that  the  source  of  irritation  is  merely 
a  number  of  small  uric-acid  stones;  and  by  elimination  of 
an  excess  of  alkali  by  the  kidney  these  are  slowly  dis- 
solved, or  at  least  sufficiently  diminished  in  size  to  permit 
their  passage  down  the  ureter.  Certain  it  is  that  under 


224  SURGICAL  THERAPEUTICS 

this  line  of  treatment  such  small  stones  are  discharged 
from  the  bladder  in  some  cases,  with  perfect  relief  of  all 
symptoms.  If  no  benefit  is  derived  at  the  end  of  three 
weeks,  it  may  be  concluded  either  that  the  stone  is  too 
large  to  be  affected  or  that  it  is  not  of  simple  uric-acid 
formation.  The  onset  of  fever  or  the  appearance  of 
much  pus  in  the  urine  demands  early  operation. 

Displaced  Kidney. — Nervous  and  pelvic  symptoms 
dependent  upon  wandering  kidney  are  more  frequent 
than  many  believe.  If  more  kidneys  had  been  anchored 
and  fewer  ovaries  removed,  gynecologists  would  not  have 
been  so  severely  criticized  by  neurologists  as  they  have 
been;  and  many  a  suffering  invalid  would  have  been  cured 
instead  of  merely  improved  (by  the  rest  in  bed).  When- 
ever a  kidney  is  found  completely  below  the  ribs  it  is 
making  serious  traction  on  the  nerves  and  vessels,  it  is 
causing  trouble  and  should  be  replaced  and  sutured.  It 
is  almost  phenomenal  how  quickly  and  permanently  many 
chronic  invalids  may  be  restored  to  perfect  health  by 
fixation  of  a  loose  kidney  which  had  escaped  recognition 
for  perhaps  years.  Why?  Not  because  the  doctor  did 
not  know  about  loosened  kidney,  but  because  he  had  been 
"too  busy"  to  make  careful  examination;  or  had  been 
too  deeply  interested  in  "local  treatments"  of  a  wholly 
innocent  uterus  through  a  speculum  (for  dollars?);  or  too 
much  of  a  doser  to  believe  hi  surgical  measures.  Some 
become  so  wholly  absorbed  in  the  administration  of  drugs 
as  to  lose  sight  of  the  necessity  for  operative  treatment 
of  certain  conditions.  This  is  deplorable,  but  true.  Others, 
knowing,  fear  to  advise  operation,  as  the  patients  may 
lose  faith  in  them  if  they  admit  there  is  anything  they 
cannot  cure!  This  is  cowardly,  but  also  true. 

Kidney  Operations:  Treatment  After. — Three 
things  are  prominent  after  kidney  operations,  especially 
nephrectomy:  vomiting,  pain  and  drainage.  The  first 


KIDNEY  225 

two  may  be  controlled,  usually,  by  hypodermics  of 
hyoscine  hydrobromide  (gr.  i-ioo)  and  morphine  (gr. 
1-4)  every  three  to  six  hours,  this  combination  being  better 
than  plain  morphine  which  has  a  tendency  to  check  urine- 
secretion;  and  i -zoo  grain  of  digitalin  may  be  added  with 
advantage.  Immediately  after  operation  (when  the  pelvis 
of  the  kidney  is  opened  or  the  kidney  removed)  the  tempera- 
ture rises  to  104° — 105°  F.  in  a  few  hours,  but  it  usually  drops 
to  normal  as  soon  as  the  opposite  kidney  begins  to  function- 
ate actively.  Should  the  temperature  become  subnormal 
and  vomiting  persist,  acute  sepsis  is  coming  on  and  must  be 
combated  earnestly,  with  particular  attention  to  elimination 
and  to  drainage.  The  bowels  must  be  kept  active  and  per- 
spiration induced  (pilocarpine  hypodermically  and  much 
water  by  mouth).  The  wound  is  best  opened  up  wide, 
even  if  it  has  been  partly  sutured,  washed  out  and  packed 
with  gauze.  Hypodermoclysis  is  of  value;  also  sulphate  of 
strychnine  and  sparteine  hypodermically. 

Prolapsed  Kidney  and  Insanity. — Our  hospitals 
for  the  insane  contain  thousands  of  patients  (particularly 
women)  who  suffer  from  wandering  kidney.  Many  of 
these  unfortunates,  indeed,  might  have  been  saved  loss 
of  their  equilibrium  by  timely  suspension  of  the  loosened 
kidneys.  This  must  not  be  construed  as  a  statement 
that  wandering  kidney  is  a  cause  of  insanity,  but  simply 
that  the  irritation  resulting  from  the  dragging  of  the  dis- 
placed organ  is  enough  to  unbalance  mentality.  This 
declaration  also  must  not  be  taken  as  a  mere  supposition; 
it  is  the  result  of  many  years'  study.  Asylum  physicians 
declare  it  is  not  true — because  most  asylum  physicians 
(chosen  by  political  pull  rather  than  by  any  fitness  for 
their  positions)  are  not  capable  of  making  a  diagnosis, 
save  in  exceptional  cases.  It  is  not  improbable  that  some 
of  these  patients  might  be  greatly  helped  if  not  entirely 
cured  by  correction  of  this  source  of  nerve-irritation. 


226  SURGICAL  THERAPEUTICS 

Tuberculosis  of  Kidney. — The  old  idea  that  renal 
tuberculosis  is  secondary  to  that  of  the  bladder  is  now 
exploded,  and  its  hematogenous  origin  is  very  generally 
recognized.  This  view,  based  upon  clinical  experience, 
is  also  supported  by  the  experimental  findings  of  Baum- 
garten,  that  tuberculous  infection  in  the  genitourinary 
system  follows  the  flow  of  the  secretions,  from  the  testicles 
to  the  prostate  and  from  the  kidneys  to  the  bladder.  Renal 
tuberculosis  is  generally  at  first  unilateral,  and  in  spite 
of  the  fact  that  it  may  occasionally  become  latent  for 
longer  or  shorter  periods,  its  usual  course  is  progressive, 
and  experience  has  demonstrated  that  early  nephrectomy, 
before  involvement  of  the  bladder  occurs,  is  the  best 
treatment  for  renal  tuberculosis.  The  existence  of  tuber- 
culosis elsewhere,  if  not  too  far  advanced,  is  not  a  contra- 
indication; even  bad  cases  of  vesical  tuberculosis  may 
improve  or  recover  after  operation.  Removal  of  the 
ureter  is  rarely  necessary. 

In  the  comparatively  small  but  constantly  increasing 
number  of  patients  in  whom  the  diagnosis  can  be  made 
before  much  destruction  of  kidney-tissue  or  involvement 
of  other  organs  has  taken  place,  hygiene  and  climate 
should  have  a  chance  before  the  kidney  is  removed.  By 
careful  attention  to  diet,  elimination  of  waste-products 
by  an  active  colon,  outdoor  life,  tonic  treatment  and  the 
use  of  some  formalin  preparation  to  sterilize  the  urine, 
one  may  often  do  away  with  the  necessity  for  an  opera- 
tion. For  the  more  numerous  later  cases  nephrectomy 
is  always  the  operation  of  choice,  and  should  be  done  in 
every  instance,  if  the  patient  can  stand  it  and  he  has  another 
kidney  capable  of  doing  a  fair  amount  of  work,  whether 
the  disease  has  passed  beyond  the  limits  of  the  organ  to 
be  removed  or  not,  and  whether  the  other  kidney  be  in- 
volved or  not.  But  when  it  is  presumed  that  the  other  kid- 
ney is  seriously  crippled,  it  is  better  to  leave  the  patient 


KIDNEY  227 

to  internal  treatment  alone;  attempts  at  drainage  lead  to 
sepsis  too  often. 

Wandering  Kidney. — In  abnormally  loose  kidney 
the  pathological  epiphenomena  may  be:  (i)  Those  due 
to  the  kidney;  (2)  those  due  to  traction  upon  viscera  con- 
nected with  the  kidney; 

1.  There  is  a  traction  upon  the  renal  vessels  more 
on  the  right  than  on  the  left,  which  results  in  a  nicking 
constriction,  torsion,  or  even  rupture  of  the  intimal  coat 
with   thrombosis;   a   serious   congestion    (stasis)  with  en- 
enlargement  of  the  organ  often  follows  this  interference 
with  the  blood-supply.    The  ureter  with  this  downward  dis- 
placement is  kinked  or  twisted,  hydronephrosis  occurring, 
which  is  relieved  by  recumbence;  or  the  acute  angle  of 
the  insertion  of  the  ureters  into  the  pelvis  may  become 
hypertrophied,  a  valvular  formation  resulting,  giving  rise 
to  an  intermittent  or  permanent  hydronephrosis.     Pelvic 
congestion,   plus   infection,   is  the   forerunner   of   calculi, 
undermining  the  kidney  substance   and  kidney,  or   peri- 
nephritic  abscess  in  the  majority  of  cases. 

2.  The   peritoneal   and   cellular   attachments   of   the 
kidney  to  surrounding  organs  are  of  the  greatest  import- 
ance.   A  well-defined  dislocated  kidney  of  the  right  side 
producing   decided  traction   upon   the   reflections   of   the 
liver,    duodenum,    and    pylorus    mechanically    interferes 
with  the  normal  functions  of  these  organs,  obstruction  of 
the  biliary  and  pancreatic  channels,  cholecystitis,  chole- 
lithiasis, biliary  cirrhosis,  pancreatitis,  pyloric  and  gastric 
ulcer  and  duodenitis  being  some  of  the  lesions  in  this  loca- 
tion which  are  directly  traceable  to  the  wandering,  mis- 
placed kidney.  (Byron  Robinson). 

Kidneys  prolapsed  to  such  a  degree  that  the  entire 
organ  may  be  easily  palpated,  should,  generally,  be  sub- 
jected to  operation;  those  which  do  not  fall  far  below  the 
rib-margin  may  be  held  up  fairly  well  by  a  straight-front 


328  SURGICAL  THERAPEUTICS 

corset,  put  on  while  the  patient  is  in  the  recumbent  posi- 
tion, or  by  a  specially  built  supporter.  It  should  always 
be  remembered  that  while  wandering  kidney  is  essentially 
a  surgical  disease  it  is  often  associated  with  neurasthenia, 
so  that  mere  fixation  does  not  entirely  relieve:  iron,  arsenic, 
strychnine  and  food  as  well  as  laxatives  are  imperatively 
indicated. 

KNEE:   INFLUENZA  OF 

Infection  of  the  knee-joint  with  the  organism  of  influenza 
(Pfeiffer's  bacillus)  is  not  at  all  uncommon,  in  fact  it  seems 
to  be  more  frequent  than  either  typhoid  or  pneumococcus 
infection  of  that  articulation.  A  peculiar  feature  of  this 
form  of  disease  is  that  long  intervals  of  months  or  years 
may  lie  between  the  acute  attack  of  influenza  and  these 
articular  troubles.  In  a  number  of  cases  the  influenza 
never  subsides  entirely,  this  chronic  influenza  (the  existence 
of  which  is  not  universally  admitted)  being  shown  by  the 
persistence  of  certain  subjective  sequelae  of  influenza, 
especially  of  a  neurasthenic  character,  with  a  marked 
tendency  to  take  cold,  also  chilliness  and  profuse  per- 
spiration on  the  slightest  provocation;  also,  often,  by  the 
persistence  of  the  "strawberry  tongue";  and  frequently 
by  persisting  tenderness  along  the  intercostal  nerves. 

At  the  beginning  of  the  joint-trouble  the  symptoms 
may  be  acute  (or  subacute)  and  are  generally  regarded 
as  "rheumatism,"  but  they  soon  are  seen  to  be  chronic. 
The  chief  site  of  complaint  is  the  condyle,  with  pain  like 
that  of  osteomyelitis  of  the  epiphyses,  frequently  followed 
by  a  persistent  weakness  of  the  knee,  with  tenderness  on 
pressure  of  the  condyle.  The  existence  of  this  form  of 
bone-disease  has  only  recently  been  suspected,  most  sur- 
geons having  formerly  regarded  this  tenderness  of  the 
bone  as  a  purely  nervous  phenomenon.  Severe  cases 
with  a  high  fever  and  much  pain  are  very  exceptional, 


LEUKEMIA  229 

and  practically  never  end  in  suppuration,  provided  they 
are  properly  treated  by  placing  the  limb  at  rest.  Resection 
is  but  rarely  required.  Thick  brownish  red  pus  is  some- 
times found  in  a  circumscribed  intraarticular  focus.  Bac- 
teria, as  a  rule,  can  not  be  demonstrated. 

The  treatment  of  these  patients  having  influenza  of 
the  knee  should  consist  in  complete  rest  of  the  limb,  pref- 
erably rest  in  bed,  but  this  will  hardly  prove  feasible  in 
chronic  cases.  Internally  it  is  best  first  to  prescribe 
sodium  salicylate  with  antipyrin,  which  will  be  found  to 
be  successful  also  in  long-standing  cases.  Quinine  is 
administered  in  the  presence  of  enlargement  of  the  spleen. 
Hot-air-baths  or  Bier's  congestion  method  may  prove  useful 
in  certain  cases,  whereas  ointments  and  other  remedies  for 
gout  and  rheumatism  will  be  found  to  be  of  no  value. 
The  patient  should  be  instructed  to  guard  as  carefully 
as  possible  against  taking  cold. 

LEUKEMIA 

X-Ray  Treatment. — Prompt  subsidence  of  the  enlarge- 
ment of  the  glands  found  in  leukemia  may  be  expected 
from  the  careful  use  of  x-radiance.  Nor  is  the  diminution 
limited  to  those  subjected  to  the  direct  influence:  the  glands 
at  a  distance  from  the  exposed  part  will  also  yield.  In 
application  of  the  ray  the  spleen  and  the  glands  of  the  neck 
are  the  parts  placed  close  to  the  tube;  it  is  not  necessary  to 
ray  the  bones  in  the  splenomedullary  variety  of  the  dis- 
ease. It  is  possible  that  Roentgenization  of  the  liver  also 
might  prove  beneficial.  It  is  best  to  eliminate  the  non- 
penetrating  rays,  since  these  have  no  effect  on  deep  struc- 
tures while  they  irritate  or  burn  the  skin.  This  is  ac- 
complished by  filtering  the  rays  through  diachylon  (usually 
four  layers)  which  readily  adheres  to  the  skin  and  screens 
the  ray  in  such  a  way  that  the  irritating  action  is  arrested 
while  the  curative  rays  are  uninterrupted.  The  neck 


230  SURGICAL  THERAPEUTICS 

should   be    rayed  even  if    the    cervical    glands    are   not 
enlarged. 

But  the  leukemia  is  simply  benefited,  not  cured,  so 
far  as  now  demonstrable  by  the  Roentgen  ray.  Even  the 
splenomyelogenous  variety  improves  under  its  influence. 
The  action  seems  to  be  of  two  kinds:  the  local  influence  on 
the  spleen  and  glands  characterized  by  inflammatory 
reaction,  if  treatment  is  pushed  vigorously,  and  later  by 
the  breaking  down  and  disintegration  of  gland-tissue  and 
the  formation  of  leucotoxin,  which  either  has  an  inhibitory 
action  on  the  manufacture  of  leucocytes  by  the  bone-mar- 
row or  destroys  the  leucocytes  already  formed.  In  no 
case  has  the  splenic  tumor  disappeared  entirely.  With  a 
discontinuance  of  the  Roentgen  ray,  the  disease,  at  varying 
periods,  returns.  Acute  cases  are  not  benefited  at  all  by 
treatment.  Chronic  cases  respond  more  rapidly  than 
subacute  cases.  The  probability  is  that  the  ray  holds 
the  disease  in  abeyance  but  does  not  cure  the  patient, 
and  above  all,  exerts  the  "suggestive"  influence  upon  a 
mind  ready  to  grasp  any  chance  of  escape  from  a  disease 
pronounced  incurable. 

LID  ABSCESSES 

Abscesses  of  the  lids  do  not  differ  materially  from  foci 
of  suppuration  elsewhere  save  in  their  causes  and  peculiar 
treatment  necessitated  by  the  proximity  of  the  delicate 
conjunctiva.  They  occur  much  more  frequently  in  chil- 
dren than  in  adults,  and  are  due  either  to  trauma  or  to 
some  illness  of  pus-producing  germ:  grippe,  scarlet-fever, 
etc.,  the  worst  being  those  due  to  infection  with  strepto- 
cocci; when  such  is  the  cause,  and  the  child  weakens,  a 
gangrenous  condition  may  arise.  As  soon  as  noted,  hot 
compresses  may  be  applied,  calcium  sulphide  given  inter- 
nally, and  efforts  made  to  strengthen  the  patient  as  much 
as  possible:  forced  feeding  and  tonic  remedies.  As  soon 


LIVER  231 

as  it  is  seen  that  pus  is  sure  to  form  the  abscess  must  be 
opened  by  free  incision  and  kept  clean  by  frequent  bathing 
in  mild  antiseptic  solutions  like  the  liquor  antisepticus 
alkalinus  of  the  U.  S.  P. 

LIVER 

Abscess  of  Liver. — In  cases  of  doubt,  when  symptoms 
point  pretty  clearly  to  the  liver,  aspiration  and  explora- 
tory incisions  are  justifiable,  but  when  the  liver  itself  gives 
rise  to  no  suspicions,  operative  measures  are  not  advisable. 
There  are  some  cases  in  which  the  liver  is  not  enlarged, 
and  it  is  only  by  exclusion  that  this  organ  comes  under 
suspicion.  Axisa  has  found,  by  observations,  that  a  leuco- 
cytosis  with  a  simultaneous  alimentary  levulosuria,  espe- 
cially if  accompanied  .by  a  reverse  relation  between  the 
ammonia  and  urea  in  the  urine,  point  to  an  inflammatory 
process  in  the  liver,  even  if  the  diagnosis  is  not  thus  ren- 
dered absolutely  certain.  On  repeated  examinations,  if 
the  blood  and  urine  continue  to  give  these  results,  the 
diagnosis  is  tolerably  sure  and  exploratory  abdominal  sec- 
tion is  to  be  made.  The  only  treatment  is  thorough  evacua- 
tion of  every  focus  of  suppuration. 

Cirrhosis  of  the  Liver. — While  cirrhosis  of  the  liver 
cannot  be  cured  by  surgical  means  its  most  distressing 
and  alarming  symptom,  ascites,  may  be  done  away  with 
by  the  Talma-Morrison  operation.  In  many  instances 
the  patient  has  not  only  been  relieved  temporarily  but  life 
has  been  prolonged  many  years.  By  stripping  the  parietal 
peritoneum  from  its  attachments,  over  a  large  area,  and 
suturing  the  great  omentum  into  the  pocket  thus  formed, 
a  free  anastomosis  is  soon  established  between  the  veins 
of  the  omentum  and  those  of  the  belly-wall,  with  the 
result  that  the  engorgement  of  the  portal  circulation  is 
speedily  and  permanently  relieved,  to  the  great  benefit  of 
the  patient. 


232  SURGICAL  THERAPEUTICS 

Cirrhosis  of  the  Liver:  lodoform  for. — lodoform 
(dose  i  decigram  to  a  half  gram:  i  grain  to  7  grains)  has 
been  highly  extolled  as  a  remedy  for  cirrhosis  of  the  liver, 
especially  for  the  stage  of  hypertrophy.  This  may  be 
given  three  times  a  day,  but  its  use  must  be  long-continued 
to  effect  great  improvement.  The  urine  must  be  carefully 
watched  for  hematuria  and  albuminuria;  and  instantly  dis- 
continued, or  the  dose  reduced  to  the  minimum,  on  the 
appearance  of  either,  as  death  has  occurred  from  too  much 
iodoform,  the  autopsy  showing  glomerular  nephritis. 

LUMBAGO-MYALGIA:   MUSCULAR  STRAIN 

Frequently  in  a  socalled  lumbago  the  trouble  is  a  strain 
of  the  muscles  of  the  back  and  loins  and  not  of  neuralgic 
character  at  all.  The  injection  of  half  a  gram  (8  grains) 
of  antipyrin  into  the  muscles  at  the  most  painful  spot  will 
give  instant  and  permanent  relief;  even  the  injection  of 
pure  water  does  good  in  some  cases.  Ironing  the  back 
with  a  hot  flat-iron  will  cure  other  cases,  as  will  also 
deep  massage  of  the  affected  muscles.  ^Following,  either 
a  belladonna  plaster  should  be  applied,  as  it  cheers  the 
patient's  mind  and  eases  his  back.  If  persistent,  a  blister 
may  be  applied.  It  should  always  be  borne  in  mind  that 
a  great  many  backaches  depend  upon  an  overloaded 
colon  and  that  a  good  saline  laxative  will  afford  a  more 
prompt  relief  than  any  other  treatment. 

LUNG 

Lang  Complications  after  Abdominal  Section. — 
Septic  pneumonia  may  follow  any  operation  for  abscess 
of  any  part  of  the  abdominal  cavity;  but  the  larger  pro- 
portion of  pulmonary  complications  occur  after  operations 
above  the  umbilicus  rather  than  after  those  in  the  lower 
half  of  the  abdomen.  Postoperative  pneumonia  has  an 
average  mortality  of  65  percent.  In  about  a  quarter  of 


LUPUS  233 

the  cases  the  pneumonia  is  due  to  aspiration  from  ether- 
anesthesia.  Carcinomatous  cachexia  affords  an  unmis- 
takable predisposition  to  lung  complications.  Pneumonia 
is  observed  rarely  after  operations  on  the  gall-bladder, 
while  it  occurs  in  about  35  percent  of  the  gas;rostomies 
on  account  of  cancer,  and  in  6  percent  of  resection  of  the 
stomach.  Appendicitis  and  complicating  peritonitis  are 
responsible  for  most  of  the  cases  of  pneumonia;  aspiration 
during  the  anesthesia  is  the  usual  cause,  a  tendency  to 
thrombosis  and  embolism  of  the  lungs  being  quite  rare. 

Surgery  of  the  Lang. — The  surgery  of  the  lung  is 
yet  in  its  infancy.  Much  is  to  be  expected  in  future, 
when  technic  has  been  perfected.  At  present  surgical 
treatment  is  confined  practically  to  bronchiectasis,  gangrene 
and  localized  abscesses.  What  has  thus  far  been  accom- 
plished? Garre  has  collected  statistics  thus:  Of  400 
cases  of  lung  abscesses,  gangrene  and  bronchiectasis,  300 
were  reported  as  "cured"  by  the  pneumotomy.  The 
mortality  of  the  operation  was  25  percent.  In  how  many 
of  these  cases  "cure"  was  permanent  is  impossible  to  say 
from  the  literature.  Garre's  own  experience  leads  him 
to  believe  that  in  the  acute  cases  (gangrene  and  acute 
abscesses)  one  may  practically  always  expect  permanent 
cure.  The  prognosis  is  less  favorable  for  gangrene  than 
for  abscess.  For  bronchiectasis  the  reported  percentage  of 
cures  he  found  to  be  60  percent;  but  these  "cures"  were 
not  always  definite.  Of  47  cases  of  lung  tuberculosis, 
surgically  treated,  26  showed  marked  improvement  or 
"stillstand"  of  the  tuberculous  process.  In  actinomycosis 
the  prognosis  is  decidedly  bad,  but  there  are  four  cases 
in  the  literature  reported  as  cured. 

LUPUS 

Lupus  is  a  chronic  disease  of  the  skin  (and  sometimes 
mucous  membranes),  of  tuberculous  origin,  characterized 


by  the  formation  in  the  connective  tissue  of  nodules  of 
granulation-tissue;  terminating  in  ulceration.  The  most 
certain  remedy  is  early  and  complete  excision.  Next-best 
is  cauterization  with  the  Paquelin  cautery — thorough 
eradication.  The  Roentgen  ray  has  also  given  excellent 
results  in  this  trouble,  possibly  better  than  in 'any  other 
disease.  In  the  treatment  of  lupus  Brooke's  formula  is 
much  used: 

Zinc  oxide    8.0  (drs.    2) 

Starch     8.0  (drs.    2) 

Vaseline 16.0  (drs.    4) 

Mercury  oleate   32.0  (oz.      i) 

Salicylic  acid 1.5  (grs.  20) 

Ichthyol   1.5  (gtt.  20) 

Oil  of  lavender  to  scent. 

Umber  or  Armenian  bole  may  be  added  in  sufficient  quantity 
to  make  the  ointment  match  the  skin  and  thus  be  less 
conspicuous. 

LYMPHADENITIS    (TUBERCULOUS) 

In  the  management  of  tuberculous  adenitis  the  internal 
treatment  and  the  local  are  rather  more  important  than 
the  operative.  Yet  no  one  should  persist  in  internal  medi- 
cation and  local  applications  until  burrowing  abscesses 
have  formed  or  the  glandular  substance  has  broken  down 
and  is  about  to  discharge  through  the  skin;  for  such 
treatment  would  lead  to  disaster — the  formation  of  indo- 
lent, discharging  sinuses,  with  danger  of  systemic  trouble 
from  mixed  infection — for  as  soon  as  the  "cold  abscesses" 
open  there  is  engrafted  on  the  tuberculous  soil  the  staphylo- 
coccus,  even  if  not  the  streptococcus.  Hence  it  is  very 
easy  to  wait  too  long,  especially  as  the  patient  makes  but 
little,  if  any,  complaint.  But  so  long  as  the  tuberculous 
focus  seems  limited  within  the  capsule  (evidence:  non- 
adherence  to  surrounding  tissues)  it  is  safe  to  abstain  from 


LYMPHOSARCOMA  VS.  HODGKIN'S  DISEASE      235 

surgical  interference — often  for  weeks  and  sometimes  per- 
manently. Non-operative  treatment  consists  of  (a)  general 
measures:  increase  of  food,  maximum  of  outdoor  life  in 
the  sunshine,  encouragement  of  proper  elimination  by 
kidneys  and  bowels  (excess  of  water  and  saline  laxatives, 
but  no  physic);  (b)  the  administration  of  drugs  calculated 
to  strengthen:  notably  iron,  arsenic  and  strychnine,  creosote, 
with  small  quantities  of  alcohol  just  before  each  meal 
(sweet  wines  or  whisky  with  glycerin  or  syrup  just  before 
eating  causes  a  patient  to  take  more  food  than  he  does 
without  the  alcoholic  agent);  and  (c)  local  use  of  either 
tincture  of  iodine  painted  on  the  affected  gland — its  absorp- 
tion aided  perhaps  by  the  negative  pole  of  a  galvanic 
battery  (50  to  75  milliamperes) — or  an  ointment  of  ichthyol 
in  lanolin.  Massage,  aside  from  the  gentle  rubbing  in 
of  ointment,  must  never  be  permitted;  rupture  of  the 
capsule  of  a  non-inflamed  tuberculous  gland  is  likely  to 
have  early  phthisis  as  a  result.  As  soon  as  the  gland 
softens,  or  becomes  adherent  it  should  be  excised.  Recur- 
rence is  to  be  anticipated  in  near-by  glands. 

LYMPHOSARCOMA  VS.  HODGKIN'S  DISEASE 

It  is  now  claimed  by  some  pathologists  that  lymphosar- 
coma  affecting  the  glands  of  the  neck  is  not  the  same  as 
Hodgkin's  disease,  though  the  two  names  have  heretofore 
been  used  interchangeably  by  most  authors.  Lymphosar- 
coma,  it  is  said,  can  be  distinguished  from  true  sarcoma 
on  the  one  hand  and  from  lymphatic  leukemia  and  the 
lymphosarcomatosis  of  Sternberg  on  the  other;  while  the 
lesions  of  Hodgkin's  disease  are  of  still  different  character. 
There  are  some  cases,  however,  in  which  it  is  difficult  to 
differentiate  even  by  microscopic  examination,  bearing  like 
evidences  of  leukemia  and  Hodgkin's.  But  in  any  case, 
any  rapidly  growing  tumors  of  the  lower  part  of  the  neck 
should  be  removed,  the  region  subjected  to  vigorous  x-ray 


236  SURGICAL  THERAPEUTICS 

treatment  as  soon  as  possible,  and  large  doses  of  arsenic 
administered  internally. 

MACEWEN'S  CHROMIC  CATGUT 

The  MacEwen  method  of  preparing  catgut  is:  To  one 
ounce  of  water  and  glycerin  add  12  grains  of  chromic- 
acid  crystals.  Immerse  the  catgut,  carefully  washed,  in 
ether  for  twenty-four  hours  to  remove  surplus  fat,  and 
then  soak  for  ten  days  in  the  chromic  solution.  For 
preservation  MacEwen  uses  5-percent  phenol  solution, 
but  most  surgeons  now  prefer  alcohol,  65  percent. 

MALIGNANT  PUSTULE 

As  soon  as  malignant  pustule  is  recognized  the  affected 
area  should  be  treated  by  use  of  the  Paquelin  cautery, 
drawing  a  deep  gutter  around  the  group  of  vesicles  by 
successively  inserting  the  fine  cautery  point  deeply  into 
the  skin;  when  the  pustule  is  thus  isolated  it  is  opened 
with  a  crucial  incision.  Subsequently  it  is  not  necessary 
to  use  the  cautery.  But  at  a  distance  of  five  or  ten  centi- 
meters from  the  pustule,  one  should  make  a  second  circle 
by  injecting  iodine  repeatedly  under  the  skin,  using  the 
ordinary  tincture  of  iodine.  A  few  drops  are  to  be  injected 
at  each  place,  using  altogether  a  hypodermic  syringeful. 
In  severe  cases  it  is  necessary  to  repeat  this  injection  on 
the  following  day.  If  there  should  be  much  edema  present 
at  the  time,  free  incisions  must  be  made,  sufficiently  numer- 
ous to  relieve  tension.  Compresses  of  moist  sublimate 
gauze  are  placed  upon  the  pustule  for  a  dressing.  Rarely, 
when  the  patient  becomes  very  weak,  it  is  best  to  give 
injections  of  camphorated  oil.  The  results  of  this  mode 
of  treatment  are  excellent.  The  edema,  which  usually 
is  great,  either  does  not  appear  or  quickly  subsides;  the 
general  condition  improves  rapidly,  and  the  danger  is 
considerably  diminished. 


MASTOIDITIS  237 

MARTIN'S  BANDAGE 

The  name  "Martin's  bandage"  is  vised  for  a  long, 
india-rubber  bandage  from  6  to  20  feet  long  which  is 
often  employed  in  the  treatment  of  varicose  veins,  ulcers 
of  the  leg  and  for  chronic  effusion  in  joints.  It  may  also 
be  used  as  a  tourniquet,  being  rather  better  than  the 
Esmarch,  so  much  employed. 

MASTOIDITIS 

Inflammation  of  the  mastoid  varies  greatly  in  the  indi- 
cations for  treatment,  the  proper  management  depending 
considerably  upon  the  cause.  Therefore  it  is  necessary, 
as  Williams  points  out,  to  differentiate  between  forms  due 
to  chronic  and  those  arising  from  acute  suppurative 
conditions  of  the  middle  ear,  and  between  acute  inflamma- 
tions of  hitherto  healthy  mastoids  and  acute  exacerbations 
of  chronic  disease. 

We  should  operate  upon  the  mastoid:  In  acute  sup- 
purative inflammation  of  the  middle  ear,  accompanied 
by  symptoms  of  mastoid  involvement,  or  by  head  symp- 
toms of  any  kind  which  persist  for  more  than  two  days 
despite  free  drainage  from  the  middle  ear  and  proper 
palliative  treatment;  when  there  is  an  obvious  abscess  behind 
the  ear  as  a  result  of  acute  mastoid  disease;  for  profuse  dis- 
charge from  the  ear  persisting  in  spite  of  treatment  beyond 
two  months  after  an  attack  of  acute  suppurative  otitis 
media;  for  acute  mastoid  disease  occurring  in  the  course  of 
chronic  otorrhea;  for  chronic  suppuration  of  the  middle 
ear  which  persists  in  spite  of  years  of  treatment  by  free 
drainage,  cleanliness  and  local  applications;  for  cholestea- 
toma,  fistulous  openings  in  the  mastoid  and  facial  paralysis 
occurring  in  chronic  otorrhea.  Intra cranial  complica- 
tions of  ear  disease  always  demand  opening  into  the  mastoid 
as  a  part  of  the  search  for  the  more  serious  lesion,  provided 


238  SURGICAL  THERAPEUTICS 

that  a  more  complete  mastoid  operation  has  not  already 
been  performed. 

He  who  would  operate  under  such  conditions  must 
have  a  thorough  knowledge  and  experience  in  the  prin- 
ciples and  technic  of  modern  operative  surgery,  with 
a  very  special  knowledge  of  the  anatomy  of  the  temporal 
bone  and  of  all  its  associated  structures.  He  should  have 
operated  previously  on  the  cadaver,  and  he  should  have 
assisted  often  in  mastoid  operations  upon  the  living  subject. 

When  symptoms  point  to  infection  of  the  mastoid  cells, 
the  ear  must  be  thoroughly  cleaned  out  by  washing  with 
hydrogen  dioxide,  dried  and  filled  with  powdered  boric 
acid.  Sufficient  codeine  sulphate  should  be  given  to  con- 
trol the  pain;  alone  if  there  is  little  rise  in  temperature — 
with  acetanilid  if  there  be  much  fever.  As  soon  as  fever 
persists  and  swelling  is  noted  the  cells  and  antrum  must 
be  promptly  and  thoroughly  opened  and  drained.  A  per- 
sistent elevation  of  temperature  after  a  radical  operation 
for  mastoiditis  should  lead  one  to  suspect  the  possibility 
of  a  complicating  brain  abscess.  If  the  fever  shows  wide 
fluctuations  of  temperature  a  sinus  thrombosis  is  more 
probably  the  cause.  In  either  case  the  services  of  an 
experienced  general  surgeon  (not  a  mere  aurist)  should  be 
sought  and  the  diseased  focus  drained. 

MOLES:    REMOVAL  OF 

Small  moles  may  readily  be  removed  by  the  application 
of  a  solution  of  sodium  ethylate.  A  drop  of  the  solution 
is  placed  on  the  blemish,  a  scab  forms,  and  when  the  scab 
drops  off,  the  mole  (or  even  a  small  nevus)  will  have  dis- 
appeared, leaving  only  a  trace  of  a  scar. 

Moles  and  Cancer. — The  liability  of  old  warts  and 
moles  to  take  on  epitheliomatous  degeneration  late  in  life 
is  now  so  well  proven  that  it  is  best  to  remove  all  such 
growths  whenever  a  patient  is  under  general  anesthesia  for 


MYOSITIS  239 

other  work,  and  they  should  be  removed  under  local 
anesthesia  whenever  they  show  signs  of  becoming  ulcerated 
or  of  increasing  in  size. 

MOUTH  ULCERS 

Persistent  ulcers  of  the  mouth,  not  of  syphilitic  origin, 
are  best  treated  by  burning  with  stick  silver  nitrate, 
then  using  a  saturated  solution  of  chlorate  of  potassium 
containing  a  little  thymol  as  a  mouth-wash.  The  burning 
may  be  repeated  every  two  days;  but  few  treatments  will 
be  needed.  Ulcers  which  persist  in  spite  of  this  treatment 
are  (i)  tuberculous,  (2)  syphilitic,  or  (3)  cancerous,  and 
demand  careful  investigation;  excision  of  a  small  piece 
of  involved  tissue,  under  cocaine  anesthesia,  for  examina- 
tion, is  justifiable  in  suspicious  cases. 

MUSCLES 

Angioma. — -According  to  Seitter  angiomata  of  the 
muscles  have  a  great  tendency  to  become  malignant  and 
to  recur  after  removal.  Hence,  he  advises  that  the  entire 
muscle  must  be  excised,  unless  the  angioma  is  distinctly 
encapsulated.  If  the  growth  is  very  large  it  may  be  neces- 
sary to  remove  an  entire  group  of  muscles  or  even  amputate 
the  limb. 

MYOSITIS 

As  remedies  for  muscular  inflammation  we  may 
enumerate:  rest,  as  secured  by  mechanical  devices,  splints, 
bandages,  etc.;  local  sedatives,  such  as  lead  in  lotion  or 
ointment,  bismuth  subnitrate  mixed  to  creamy  consistency 
with  water  and  applied  for  one  or  two  days;  cold  or  hot 
water  applications;  gentle  massage  with  camphor  or  with 
mild  mercurial  ointments  to  subdue  active  inflammation 
and  excite  the  absorption  of  debris;  mild  applications  of 
the  faradic  current,  the  positive  pole,  too  weak  to  excite 


240  SURGICAL  THERAPEUTICS 

pain;  and  iodine  in  ointment  or  tincture.  Internally  our 
treatment  is  limited  to  keeping  the  bowels  clear  and  clean, 
restraining  the  fecal  toxin-absorption  that  reacts  so  un- 
favorably on  enfeebled  tissues,  and  possibly  the  use  of 
minute  doses  of  veratrine,  which  has  a  specific  application 
to  muscular  fiber. 

Myositis  of  Abdominal  Wall* — In  the  management 
of  cases  presumed  to  be  of  internal  origin  it  must  be  re- 
membered that  a  purely  local  inflammation  of  the  abdom- 
inal muscles,  from  trauma,  may  closely  simulate  intra- 
abdominal  pathologic  conditions;  and  especially  so  since 
vomiting  may  persist  for  some  hours  after  reception  of 
the  injury,  with  considerable  fever  following.  Many 
abdomens  have  been  opened  for  this  condition,  and  every- 
thing within  the  belly  found  normal.  All  that  is  necessary 
in  these  cases  is  rest,  plus  early  incision  under  perfect 
asepsis,  if  pus  forms. 

MYXEDEMA:    POST-OPERATIVE; 

Following  removal  of  goiter  (or  other  disease  demand- 
ing total  thyroidectomy)  myxedema  may .  appear :  of  one 
or  other  of  two  different  types,  the  cretinous  and  the  adult 
myxedematous,  according  to  the  age  of  the  patient  at 
which  the  gland  is  removed.  Most  cases  occur  in  the 
white  race;  it  is  found  most  frequently  in  cold  climates, 
and  is  probably  more  frequent  in  Europe  than  in  any 
other  continent,  Great  Britian  producing  the  majority 
of  the  cases.  Females  are  more  prone  to  the  disease 
than  males. 

An  important  element  in  the  treatment  is  the  main- 
tenance of  body-warmth,  which  is  best  secured  by  mov- 
ing to  a  warm  climate  and  by  the  wearing  of  warm  clothes. 
The  bowels  must  be  regulated  and  a  good,  nutritious 
diet  provided.  Until  recently  a  great  many  different 
drugs  were  advised.  But  none  of  them  were  of  especial 


MYXEDEMA:     POST-OPERATIVE  241 

value.  Various  tonics,  as  iron,  quinine,  hypophosphites, 
were  tried.  Diuretics  and  diaphoretics  were  also  used. 
Jaborandi  (and  pilocarpine)  given  over  a  long  period  of 
time  did  in  some  cases  prove  of  benefit,  tending  to  increase 
the  secretion  of  the  thyroid  gland.  Glonoin  and  a  host 
of  other  remedies  were  tried.  Now  Davis  says  thyroid 
therapy  is  the  foremost  treatment. 

The  first  thing  in  the  administration  of  thyroid  prepa- 
ration is  to  determine  the  most  suitable  constant  daily 
use  of  the  drug;  this  can  only  be  done  by  trial  and  must 
be  determined  for  each  case.  It  is  best  to  begin  with  a 
small  dose  (one  five-grain  tablet,  or  two  grains  of  the 
extract)  once  a  day,  and  gradually  increase  in  frequency 
and  amount  until  the  symptoms  begin  to  subside.  This 
stage  of  the  treatment  has  to  be  carried  on  with  great 
care  in  all  cases  in  which  the  disease  has  lasted  for  some 
years,  in  the  aged  and  in  those  who  show  any  indication 
of  arterial  or  cardiac  degeneration. 

The  first  effect  noticed  is  the  rising  of  the  body  tempera- 
ture to  normal.  Next  there  is  a  gradual  or  even  sudden 
diminution  in  the  subcutaneous  edema,  with  a  consequent 
loss  in  the  body  weight.  There  is  also  a  restoration  of 
the  secretion  of  the  skin,  which  becomes  moist  and  soft 
and  loses  its  harsh,  dry,  roughened  character.  Very  fre- 
quently the  old  skin  is  desquamated  in  the  form  of  large 
flakes  until  an  entirely  new  epidermis  is  exposed.  The 
hair  begins  to  grow  in  the  form  of  a  fine,  thick  crop  over 
the  scalp,  pubes,  and  axilla.  The  menses  return  to  their 
normal  regularity  and  quantity.  The  urine  is  some- 
times increased  considerably  in  amount,  and  the  albu- 
minuria  and  cylindruria  disappear.  The  anemia,  how- 
ever, may  not  clear  up,  but  may  be  increased  and  accom- 
panied by  the  appearance  of  a  true  edema  of  the  feet. 
Both  these,  however,  usually  disappear  in  a  few  weeks 
when  the  patient  regains  his  normal  strength.  With  the 


242  SURGICAL  THERAPEUTICS 

physical  improvement  there  is  a  corresponding  improve- 
ment, pari  passu,  in  the  mental  and  nervous  symptoms. 
Danger  of  myxedema  should  not  deter  operation  in  urgent 
cases. 

NECK:     FURUNCULOUS  ACNE  OF 

From  the  irritation  of  a  collar-button  a  papular  eruption 
occasionally  occurs  upon  the  neck,  which  if  not  properly 
handled  soon  becomes  a  furuncle  (staphylococcus  abscess) 
or  even  a  carbuncle  (streptococcus  abscess).  The  best 
agent  to  employ  in  all  these  cases  is  sulphur.  And  the 
best  formula  is  the  sulphur  wash  of  Widal: 

Precipitated  sulphur 10.0 

Alcohol    (go-percent) 10.0 

Distilled  water 50.0 

Rose  water     50.0 

After  shaking  the  bottle,  this  is  to  be  applied  with  a  piece 
of  absorbent  cotton,  each  night,  and  in  the  morning  the 
spot  is  washed  with  soap.  This  is  the  fundamental  treat- 
ment of  all  cases  of  acne  and  will  cure  fifty  percent  of  all 
the  cases.  If  there  is  a  deep  suppuration,  the  hair  of 
the  neck  should  be  epilated  with  tweezers.  If  the  furuncle 
enlarges  and  becomes  much  indurated,  the  galvano- 
cautery  is  useful.  If  there  is  ulceration  and  a  fistulous 
granulating  surface,  it  should  be  touched  with  a  pencil 
of  silver  nitrate. 

NOSEBLEED 

When  the  usual  methods  for  the  control  of  epistaxis 
fail,  a  little  adrenalin  solution  may  be  injected  by  hypo- 
dermic syringe  beneath  the  mucous  membrane  behind 
the  bleeding  point.  If  the  injection  be  made  at  the  proper 
point,  the  ingoing  arterial  current  carries  the  solution 
directly  to  the  point  of  leakage,  with  instant  constriction 
and  blanching  of  the  mucous  membrane  and  complete 
arrest  of  the  hemorrhage. 


OPERATION:     MANAGEMENT  AFTER  243 

OPERATION  TABLE:  IMPROMPTU 

Frequently  the  only  available  table  to  use  for  an  opera- 
tion in  a  private  house  is  the  extension  dining-table. 
This  is  entirely  too  broad,  and  very  clumsy.  In  such  a 
case  a  most  excellent  table  may  be  made  by  opening  the 
table  full  length,  taking  two  of  the  leaves  and  placing 
them  lengthwise  of  the  table,  thus  making  a  narrow  strip 


upon  which  the  patient  may  lie,  and  at  which  it  is  easy 
for  the  surgeon  and  his  assistant  to  work,  as  they  stand 
in  the  openings  on  either  side.  Blankets  and  rubber 
sheet  are  to  be  strapped  to  the  narrow  section,  thus  mak- 
ing a  comfortable  bed.  The  three  parts  of  the  table  are 
then  covered  with  separate  sterilized  sheets  and  the  Kelly 
pad  placed  at  field  of  operation. 

OPERATION:    MANAGEMENT  AFTER 

Acid  Drinks  After  Operation. — When  there  has 
been  much  loss  of  blood  or  when  anesthesia  has  been  pro- 
longed there  is  always  great  thirst  after  operation — a 
thirst  which  becomes  very  distressing  if  fever  follows,  as 
it  invariably  does  in  infected  wounds.  The  desire  for 
water  arises  not  so  much  from  true  thirst  as  from  a 
harassing  dryness  of  throat  and  mouth.  Much  of  this  may 
be  relieved  by  frequent  mopping  of  lips  and  tongue  with 
a  cloth  wrung  from  ice-water.  If  the  patient  be  given 
all  the  water  desired  the  stomach  will  soon  beccme  over- 
loaded and  troublesome  vomiting  arise;  if  not,  there  will 
be  produced  loss  of  appetite  and  acute  indigestion,  and 
later  flatulence  and  even  diarrhea.  If  lemon  juice,  lime 
juice  or  dilute  phosphoric  acid  be  added  to  the  water  drank 


244  SURGICAL  THERAPEUTICS 

a  far  less  quantity  will  be  required  to  satisfy;  frequently 
after  a  small  glass  of  sour  lemonade  the  patient's  irrita- 
bility will  disappear,  the  restlessness  will  subside,  the 
pulse-rate  will  lower  and  sleep  supervene. 

Anuria  After  Operations. — Very  rarely  there  is 
total  suppression  of  urine  immediately  after  severe  opera- 
tion— the  exact  cause  of  which  is  unknown;  if  the  kid- 
ney-secretion is  not  promptly  started  up,  death  is  certain 
to  occur  within  a  few  hours.  As  soon  as  the  anuria  is 
noted,  one-tenth  grain  of  pilocarpine  may  be  given  hypo- 
dermically;  this  will  induce  almost  instantly  a  profuse 
perspiration  which  will  eliminate  a  certain  proportion  of 
retained  poisons.  Then  hypodermoclysis  must  be  resorted 
to,  a  full  quart  of  hot  normal  salt  solution  being  thrown 
into  the  cellular  tissues  of  the  buttocks  or  breast.  If  this 
does  not  cause  urine  to  flow  into  the  bladder  within  an 
hour,  intravenous  injection  of  normal  salt  solution  must 
be  made,  one  liter  (or  about  one  quart)  being  used.  In  two 
hours  this  must  be  repeated  if  the  first  does  not  suffice. 
Backache  After  Operations. — Patients  complain 
bitterly  of  backache,  particularly  after  pelvic  operation — 
due  in  great  measure  undoubtedly  to  the  ligatures  upon 
the  broad  ligament  and  other  structures.  Martin  says 
there  are  two  other  causes:  The  annoying  backache 
which  accompanies  and  follows  the  true  postoperative 
pain  is  vaguely  referred  to  the  ether,  regarded  as  a  neces- 
sary consequence  of  this,  and  is  accorded  little  considera- 
tion; yet  it  may  constitute  the  major  distress  from  which 
patients  suffer.  It  is  observed  after  all  forms  of  severe 
trauma,  and  is  due  either  to  renal  congestion  or  to  pro- 
longed dorsal  decubitus.  When  due  to  renal  congestion 
the  normal  saline  enemata  are  particularly  serviceable. 
The  decubitus  pain  is  best  relieved  by  change  in  position. 
In  the  vast  majority  of  surgical  cases,  including  those 
subject  to  intraabdominal  operation,  the  fixed  dorsal  posi- 


OPERATION:     MANAGEMENT  AFTER  245 

tion  is  not  only  unnecessary  but  probably  distinctly  harm- 
ful. Attention  to  these  points  will  often  save  the  patient 
from  considerable  unnecessary  suffering. 

Black  Vomit  After  Operations. — The  appearance 
of  black  vomit  after  an  operation  is  serious,  but  par- 
ticularly is  it  so  in  abdominal  surgery.  A  little  bile 
may  be  thrown  up  during  the  vomiting  which  follows 
prolonged  anesthesia.  This  should  not  cause  anxiety; 
but  when  the  ejecta  become  darker  and  the  vomiting 
"soft  and  easy"  without  much  straining,  it  means  oncom- 
ing acute  sepsis,  and  usually  death,  unless  prompt  and 
effective  treatment  is  instituted.  Three  things  are  neces- 
sary: (i)  The  use  of  ox-gall  and  turpentine  enema 
(ox-gall,  one  dram;  turpentine,  two  drams;  soap-suds  one 
pint)  thrown  high  in  the  sigmoid;  (2)  the  internal  admin- 
istration of  half  a  centigram  (gr.  1-12)  of  calomel  every 
hour — it  has  a  quieting  effect  on  the  stomach;  and  (3) 
the  hypodermic  injection  of  one  milligram  (gr.  1-67)  of 
eserine  salicylate  every  hour,  four  doses.  If  the  bowels 
do  not  move  freely  inside  of  eight  hours  the  calomel  must 
be  stopped  and  a  milligram  of  ekterin  given  by  mouth 
every  hour.  Washing  out  of  the  stomach  with  warm 
water  twice  a  day  does  much  to  help  arrest  the  emesis. 

Fever  After  Operations. — Shortly  after  every  ser- 
ious operation  the  temperature  rises  to  99.5°  to  100.5°  F.; 
and  remains  elevated  for  some  hours.  It  is  dependent 
upon  the  absorption  of  the  fibrin-ferment  of  the  blood 
left  in  the  wound,  even  in  spite  of  drainage  perhaps,  and 
need  not  be  regarded  seriously.  But  if  the  fever  continue 
more  than  twenty-four  hours  it  should  be  looked  after — 
it  usually  means  either  (i)  malaria  or  (2)  staphylococcus 
or  other  pus-infection.  If  a  microscopic  examination  of 
the  blood  be  made  the  plasmodium  should  be  revealed 
whenever  malaria  is  the  cause;  when  a  microscope  can- 
not be  utilized  it  is  best  to  administer  four  5-grain  cap- 


246  SURGICAL  THERAPEUTICS 

sules  of  quinine  — one  every  four  hours  until  four  have 
been  taken.  Many  patients  suffer  from  "latent  malaria" 
and  an  accident  or  operation  merely  arouses  the  plas- 
modium  into  an  activity  which  is  recognizable. 

Glonoin  After  Operations. — When  there  has  been 
great  shock  from  operation  and  the  patient  seems  about 
to  die  from  syncope,  one  one-hundredth  grain  of  glonoin 
(nitroglycerin,  trinitrin)  may  be  given  hypodermically. 
It  promptly  dilates  the  cerebral  capillaries,  and  if  the 
shock  be  purely  of  nervous  origin — i.  e.  not  due  to  loss 
of  blood — a  favorable  change  should  be  noted  very  soon. 
If  not,  a  second  dose  may  be  given  in  ten  minutes;  but  a 
third  must  not  be  injected.  If  no  hypodermic  needle  is 
at  hand  the  glonoin  tablet  may  be  put  under  the  tongue, 
whence  it  is  absorbed  with  surprising  rapidity. 

Hiccough  After  Operation. — Occasionally  a  per- 
sistent hiccough  occurs  some  hours  after  severe  injury 
or  serious  operation  and  becomes  quite  distressing  to  the 
patient.  Possibly  the  best  thing  to  control  it,  after  appli- 
cation to  the  throat  of  cloths  wrung  out  of  ice-water  has 
failed,  is  "Hoffmann's  anodyne,"  the  spiritus  aetheris  com- 
positus  of  the  U.  S.  P.  It  is  composed  of  ether,  alcohol 
and  heavy  oil  of  wine — hence  a  stimulant  of  almost  instant 
action,  yet  prolonged  as  well;  the  ether  is  taken  up  immedi- 
ately, the  alcohol  somewhat  later,  and  the  oil  of  wine 
quite  a  time  afterward.  The  dose  is  one  to  two  teaspoon- 
fuls  every  hour  until  relieved.  Sometimes  a  capsule  of 
camphor  with  musk  arrests  hiccough  which  has  resisted 
all  other  medication;  but  genuine  musk  is  very  hard  to 
obtain  at  present. 

Intestinal  Indigestion  After  Operation. — Follow- 
ing certain  abdominal  operations  (particularly  those  in 
which  there  is  prolonged  drainage  of  the  gall-bladder  with 
external  discharge  of  large  quantities  of  bile)  intestinal 
indigestion  is  something  very  distressing  and  persistent. 


OPERATION:     MANAGEMENT  AFTER  247 

In  such  cases  prompt  relief  may  be  afforded  usually  by 
ordering  a  pill  or  granule  of  bilein  and  pancreatin  with 
strychnine  and  the  intestinal  antiferments,  such  as 

Bilein o.oi      (gr.       1-6) 

Strychnine    arsenate 0.0005  (gr.  1-134) 

Pancreatin     0.06      (gr.          i) 

Sodium  sulphocarbolate 0.2        (grs.       3) 

Sodium  carbonate    0.2        (grs.       3) 

Mix.  One,  two  or  three  may  be  given  one  hour 
after  each  meal.  In  a  day  or  two  there  will  be  marked 
diminution  of  intestinal  distress,  with  almost  perfect  relief 
as  soon  as  the  excess  of  fermentation  can  be  arrested. 

Keeping  Patients  on  their  Back* — Most  surgeons 
insist  upon  patients  lying  upon  their  backs  for  many 
days  after  a  severe  operation,  patients  who  would 
strangle,  choke,  snort  and  become  blue  in  the  face  if 
they  were  to  sleep  upon  their  backs  in  health.  It  is 
unnecessary  cruelty  in  most  cases.  If  in  an  abdominal 
section  the  blood-vessels  have  been  properly  tied,  the 
patient  may  usually  be  permitted  to  lie  upon  the  side  the 
second  night;  indeed,  in  appendicitis  it  is  advisable  that 
the  patient  lie  upon  the  right  side  instead  of  the  back; 
for  if  drainage  has  been  a  necessity,  this  position  will 
facilitate  drainage,  and  if  not,  the  position  permits  the 
cecum  to  drop  into  its  normal  position  most  readily.  In 
most  other  operations  the  position  which  is  most  comfort- 
able to  the  patient  is  usually  the  best  for  ultimate  results. 
Ox-Gall  Enema. — This  excellent  injection,  so  often 
used  after  abdominal  section,  is  made  thus: 

Inspissated  ox-gall ozs.  2 

Glycerin    oz.    i 

Warm  water ozs.  5 

To  this  may  be  added,  when  there  is  need  for  early  escape 
of  gas,  one-half  ounce  of  oil  of  turpentine.  It  is  to  be  thrown 
well  up  into  the  sigmoid  when  possible. 


248  SURGICAL  THERAPEUTICS 

Phlebitis  Following  Operation. — Just  why  throm- 
bosis of  the  femoral  vein  should  follow  an  abdominal 
section  has  not  yet  been  made  clear  by  pathologists;  yet 
phlebitis  is  not  at  all  infrequent  after  the  abdomen  has 
been  opened  for  even  non-infective  conditions  like  fibroid 
tumor.  Strange  to  say,  the  left  thigh  is  most  often  involved 
even  though  the  operative  work  is  limited  to  the  right 
side  of  the  pelvis,  as  in  appendicitis.  On  the  fifth  to 
eleventh  day  the  patient  complains  of  pain  in  Scarpa's 
triangle,  the  thigh  begins  to  swell  and  great  tenderness  of 
the  entire  thigh  as  well  as  of  the  calf  quickly  follows. 
The  temperature  rises  to  100°  or  ioi°F.  and  the  patient  is 
very  uncomfortable  and  restless.  Within  thirty-six  hours 
the  picture  of  "milk-leg,"  or  phlegmasia  alba  dolens  of 
the  old  writers,  is  complete.  The  trouble  lasts  for  about 
two  weeks,  under  favorable  conditions,  but  may  go  on  to 
suppuration  and  general  sepsis  in  the  worst  cases.  Band- 
aging and  other  forms  of  compression  must  be  avoided, 
although  they  afford  comfort,  because  they  may  cause 
detachment  of  the  clot  with  fatal  pulmonary  embolism. 
It  is  best  to  apply  heat  by  means  of  the  hot  water-bag, 
or  by  flannels  wrung  from  very  hot  water  and  covered 
with  oiled  silk.  Some  of  the  kaolin  and  glycerin  com- 
pounds with  thymol  spread  on  cloth  and  covered  with 
rubber  tissue  afford  relief  and  make  the  patient  feel  that 
something  is  being  done  for  him — a  matter  of  great  impor- 
tance because  subjects  of  this  disease  become  very  dis- 
couraged. The  cataplasma  kaolini  of  the  U.  S.  P.  is 
excellent: 

Kaolin i 577  .o 

Boric  acid 45.0 

Thymol   0.5 

Oil  of  wintergreen 2.0 

Oil  of  peppermint 0.5 

Glycerin 375.0 


OPERATION:     MANAGEMENT  AFTER  249 

Internally  three  grains  of  quinine,  two  of  acetanilid 
and  one-eighth  of  sulphate  of  codeine  may  be  given  every 
three  hours,  for  the  first  day;  after  that  small  doses  of 
aconitine  or  of  veratrine  are  of  benefit,  with  a  sufficient 
quantity  of  codeine  sulphate  to  relieve  suffering.  The 
bowels  must  be  kept  loose  with  citrate  of  magnesia  or 
saline  laxative.  During  convalescence  small  doses  of 
iron  and  arsenic  are  of  value,  with  port  or  sherry  wine. 
Pulmonary  Embolism  Following  Operation. — Ac- 
cording to  Dearborn,  who  has  reviewed  the  work  of 
twenty-five  surgeons,  thrombosis  and  embolism  are  more 
common  after  operations  in  the  pelvis  than  after  opera- 
tions in  any  other  part  of  the  body.  In  a  resume  of  7,130 
gynecologic  operations  Schenck  reports  forty-eight  cases 
of  thrombosis.  Krusen  has  recently  reported  five  cases, 
four  of  which  ended  fatally,  occurring  in  twelve  years 
of  his  gynecologic  practice.  The  symptoms  in  all  these 
cases,  as  nearly  as  could  be  observed,  were  very  similar. 
The  attack  was  characterized  by  precordial  distress, 
severe  pain  and  dyspnea,  associated  with  quickened  pulse: 
the  patient  has  an  extremely  anxious  expression,  gasps 
for  breath  with  the  aid  of  all  the  auxilliary  respiratory 
muscles,  the  face  becomes  cyanosed;  cold,  clammy  sweat 
occurs;  the  mind  remains  clear,  as  a  rule,  and  death  occurs 
in  a  few  minutes,  in  spite  of  energetic  stimulation. 

To  Increase  the  Appetite  After  Operation. — Very 
frequently  after  operations  patients  complain  that  they 
have  no  appetite,  due  probably  in  great  part  to  enforced 
inactivity.  When  such  complaints  becomes  annoying  an 
enormous  appetite  may  be  produced  sometimes  by  this 
combination: 

Lysol i.o  (gr.  16) 

Ext.  gentian, 

Pulv.   glycyrrhiz.,  aa q.  s. 

Misce  et  ft.  capsul.  xvi. 


250  SURGICAL  THERAPEUTICS 

Give  one  capsule  before  each  meal.  Burger  reports 
a  number  of  cases  of  anemia  and  scrofula  in  children 
which  he  cured  with  lysol  alone,  simply  through  the  agency 
of  the  ravenous  appetite  which  it  excites.  But,  really, 
there  is  nothing  much  better  to  excite  appetite  than  the 
granules  of  quassin,  which  should  be  given  in  solution 
or  dissolved  in  the  mouth. 

Vomiting  After  Operation, — To  check  persistent 
vomiting,  and  to  secure  sleep  the  first  night  after  opera- 
tion, two  and  a  half  grams  (forty  grains)  each  of  bromide 
of  potassium  and  chloral  hydrate  may  be  given  in  clyster, 
not  more  than  four  ounces  of  water  being  used.  Almost 
instant  comfort  and  quiet  follows  the  few  minutes  of  local 
irritation. 

OPERATIONS:  PREPARATION  FOR 

Colonic  Flashing  Before  Operation. — When  pre- 
paring a  patient  for  operation  for  cholecystitis  or  for  gall- 
stones, if  there  be  marked  jaundice  of  long  standing,  it 
is  well  to  wash  out  the  colon  every  day  for  a  week  or  more, 
using  about  a  half  gallon  of  normal  salt  solution  injected 
slowly  through  a  long  rectal  tube.  At  the  same  time  the 
patient  should  be  encouraged  to  drink  much  water. 

Covering  the  Wound. — As  much  as  possible  of 
every  cut  surface  should  be  protected  by  covering  with 
gauze  or  boiled  towel ;  and  just  as  little  handling  of  the 
wound  should  be  done  as  is  consistent  with  good  work. 

Maintenance  of  Hand-Cleanness. — For  every  pro- 
longed operation  there  should  be  upon  a  convenient  chair 
or  table  a  large  bowl  of  sterile  water  in  which  the  hands 
may  be  frequently  dipped. 

If  during  the  operation  the  hands  accidentally  come 
in  contact  with  the  table,  the  patient's  clothing,  the  pad, 
the  assistant's  face  or  clothes,  they  must  at  once  be  washed 
for  a  moment  in  the  alcohol  and  then  in  the  sublimate. 


OPERATIONS:     PREPARATION  FOR  251 

If  the  operator  sweats  freely  he  should  wash  several 
times  in  the  sublimate  solution  during  a  tedious  opera- 
tion, as  the  sweat  brings  up  microorganisms  from  the 
depths  of  the  skin. 

Preparing  the  Skin  for  Operation. — If  time  per- 
mits, the  ideal  way  to  prepare  the  skin  for  operation  is 
this:  (i)  Shave  the  site  of  operation  and  at  least  six 
inches  in  each  direction  from  it;  (2)  scrub  as  thoroughly 
as  patient  will  permit,  using  a  fairly  stiff  brush  with  plenty 
or  potash  soap  (soft  soap),  if  at  hand — if  not,  then  any 
toilet  soap;  the  surgeon  or  nurse  who  uses  a  piece  of  absor- 
bent cotton  for  this  is  not  to  be  trusted,  but  a  piece  of  gauze 
may  be  substituted  for  a  brush  if  the  latter  is  not  obtain- 
able; (3)  apply  a  soap-poultice  for  eight  or  ten  hours; 

(4)  gently  scrub  with  soap  and  water  with  a  piece  of  gauze; 

(5)  dry  the  surface  and  wash  one  minute  with  common 
ether;  (6)  wash  two  minutes  with  alcohol;  (7)  cover  with 
a  large  pad  of  bichloride  gauze  and  bandage.     At  time  of 
operation  a  little  more  ether  followed  by  alcohol  should 
be  used  especially  if  the   patient   has  sweated,  and  just 
before  cutting  the  surface  may  be  rinsed  with  sublimate 
solution  i  in  2000. 

When  there  is  not  time  for  this  elaborate  preparation 
the  following  steps  are  to  be  taken — better  after  the  patient 
is  asleep:  (a)  Scrub  five  minutes  with  a  good  brush  and 
soft  soap  with  very  hot  water,  depressions  like  the  navel 
to  have  special  attention;  (b)  dry  with  a  clean  towel;  (c) 
wash  with  ether,  or  with  oil  of  turpentine  if  ether  is 
not  at  hand;  (d)  if  turpentine  is  used  the  surface  must  be 
scrubbed  again  with  soap  and  water,  if  not,  65-percent  alco- 
hol is  to  be  used  for  two  minutes,  with  particular  care  directed 
to  the  proposed  line  of  incision;  (e)  wash  for  two  minutes 
with  i-  in  2000  bichloride  solution  or  i  in  20  carbolic  acid, 
using  a  piece  of  gauze  repeatedly  saturated  with  the  solu- 
tion. Finally  surround  the  field  of  operation  by  towels 


252  SURGICAL  THERAPEUTICS 

just  out  of  the  sterilizer  or  boiler  and  not  touched  by  any- 
body save  surgeon  or  assistant. 

Preparation  Before  Scrubbing. — Before  the  hands 
are  sterilized  everything  should  be  placed  as  desired  for 
operation:  the  tables  for  instruments  and  dressings, 
the  operation-table  where  the  best  light  is  obtainable, 
the  solutions  made  for  hands  and  patient,  the  Kelly- 
pad  and  slop-jar  put  in  proper  position,  and  cotton, 
bandages,  safety-pins,  etc.,  all  arranged  where  they  can 
be  readily  reached;  for  after  the  hands  are  properly 
cleansed  nothing  not  sterile  should  be  touched  if  avoid- 
able, since  contamination  of  hands  means  repeated  wash- 
ings and  delay. 

Preparation  of  Hands. — First  and  foremost  thor- 
ough scrubbing  is  most  important.  Few  doctors  realize 
the  importance  of  perfect  hand-cleanness;  fewer  still 
take  the  trouble  to  do  the  work  as  it  should  be  done. 
Indeed  the  chief  danger  of  inexperienced  operators  is 
dirty  finger-nails. 

Immersion. — Without  drying  them  the  hands  are 
next  thoroughly  immersed  in  the  antiseptic  solutions  to 
be  used. 

If  the  permanganate-oxalic  method  is  to  be  adopted 
the  hands  and  arms  are  washed  in  the  saturated  solu- 
tion of  permanganat  e  of  potassium  until  they  are  stained 
a  very  deep-brown  color;  then  they  are  decolorized  by 
washing  in  a  strong  solution  of  oxalic  acid;  next  they  are 
immersed  in  65-percent  alcohol  for  not  less  than  two 
minutes — not  mere  " washing"  but  putting  fingers  and 
hands  in  the  solution  which  must  cover  them — at  the  last 
washing  the  forearms  with  the  alcohol;  and  finally  wash- 
ing and  soaking  not  less  than  three  minutes  in  sublimate 
solution:  i  in  2000. 

Scrubbing. — With  a  stiff  brush,  good  soap  (liquid 
ethereal  or  potash  soap  is  best,  but  any  soap  except  "laun- 


OPERATIONS:     PREPARATION  FOR  253 

dry"  will  do)  the  hands  and  fingers  must  be  scrubbed 
five  minutes,  by  the  clock.  This  seems  a  long  time; 
the  average  doctor  of  both  country  and  city  unless  requested 
to  wash  again  and  again,  will  scrub  less  than  two  minutes 
and  think  he  is  clean!  At  the  end  of  five  minutes  the 
hands  must  be  dried  carefully  upon  a  clean,  but  not 
necessarily  "sterile",  towel.  It  is  common  for  doctors 
outside  of  hospitals  to  call  any  freshly  washed  and  ironed 
towel  "sterile."  After  the  hands  are  dry  the  finger- 
nails should  be  cut  to  the  quick;  and  then  the  fuzzy,  dirty, 
tender  skin  under  the  nail  just  at  the  point  of  junction 
with  nail  carefully  cut  away  with  a  sharp  blade;  this  is 
the  neglected,  infection-carrying  part  of  the  hands,  the 
careless  attention  to  which  is  yearly  causing  more  deaths 
than  all  the  armies  of  the  earth! 

When  the  nails  have  been  properly  cut  and  the  finger- 
tips attended  to,  the  soap,  brush  and  hot  water  are  again 
used.  If  hot  water  can  be  used  while  running,  it  is  best 
to  continue  washing  under  the  spigot;  if  not,  fresh  hot 
water  must  be  used  in  the  bowl.  Scrubbing  must  now 
be  continued  for  not  less  than  five  minutes,  by  the  clock 
again,  particular  attention  being  paid  to  the  ends  of  the 
fingers,  to  the  spaces  at  the  root  of  the  nails,  to  the  palms 
of  the  hands  and  to  the  spaces  between  the  fingers. 
Especial  care  must  be  exercised  to  scrub  the  right  hand 
as  much  as  the  left. 

Not  one  physician  in  a  thousand  prepares  his  hands 
properly  when  getting  ready  to  assist  in  an  operation  or 
to  do  major  work  himself  in  emergency;  not  fifty  percent 
of  the  men  engaged  chiefly  in  operative  surgery  are  as 
careful  as  they  should  be  in  their  attention  to  their  own 
as  well  as  their  assistants'  hands.  Entirely  too  many 
men  who  claim  to  be  surgeons  content  themselves  with 
three  or  four  minutes  devoted  to  preparation  of  the  hands. 
The  man  who  occupies  less  than  twenty  minutes  in 


254  SURGICAL  THERAPEUTICS 

efforts  to  secure  hand-sterilization  in  a  capital  operation 
(not  emergency)  should  be  deemed  guilty  of  manslaughter 
if  the  patient  previously  non-infected  should  die  of  sepsis. 
And  this  is  not  the  wild  statement  of  a  "crank"  but  the 
declaration  of  a  surgeon  who  in  a  quarter-century's  work 
has  seen  entirely  too  many  lives  sacrificed  by  the  criminal 
carelessness  of  ignorant  or  thoughtless  socalled  surgeons 
or  assistants. 

Purgation  Before  Operation. — Before  every  ser- 
ious operation  the  bowels  should  be  moved  freely  if  pos- 
sible. Notably  this  is  desirable  in  abdominal  and  pelvic 
surgery  where  the  intestines  should  be  free  from  feces 
and  gas — slipping  under  the  fingers  like  ribbons.  To 
produce  this  result  compound  licorice  powder  is  com- 
monly used,  about  2  grams  (30  grains)  being  a  laxative 
and  twice  that  quantity  for  free  catharsis.  It  should  be 
given  at  night,  with  an  enema  in  the  morning.  If  opera- 
tion is  to  be  made  late  in  the  day,  epsom  salt,  rochelle 
salt  or  Abbott's  " saline  laxative"  may  be  taken  early  in 
the  morning  of  the  day  of  operation.  Care  must  be  taken 
not  to  give  so  much  physic  to  a  weakened  patient  as  to 
cause  exhaustion,  with  possible  death  from  shock. 

Solutions. — When  a  minor  operation  is  to  be  per- 
formed careful  scrubbing  of  the  hands  and  immersion 
in  sublimate  solution  is  all  that  is  required,  unless  the 
hands  have  been  recently  in  pus.  When  a  major  opera- 
tion is  to  be  made,  potassium  permanganate  and  oxalic- 
acid  solutions  must  be  employed  if  pus  cases  have  been 
handled  within  two  or  three  days.  If  not,  alcohol  and 
sublimate  may  be  relied,  upon  alone,  if  the  work  is  not 
to  be  of  very  great  length. 

a.  Permanganate  Solution. — Into  one  bowl  holding 
at  least  half  a  gallon  of  boiled  water  a  handful  of  per- 
manganate of  potassium  is  thrown — as  much  as  will 
dissolve  and  leave  a  little  on  the  bottom. 


OPERATIONS:     PREPARATION  FOR  255 

b.  Oxalic  Solution. — In  a   similar    bowl  in    a  quart 
or  more  of  water  a  like  amount  of  oxalic  acid  is  dissolved. 

c.  Alcohol. — A  third   bowl   should   contain  8  ounces 
of  pure  alcohol  with  four  ounces  of  boiled  water  added. 

d.  Sublimate. — Enough  tablets  of  bichloride  of  mer- 
cury should  be  dissolved  in  two  quarts  of  water  to  make 
a  solution  of  the  strength  of  i  in  2000.     A  porcelain  bowl 
must  be  used.     It  should  be  wide  enough  to  admit  the 
hands  with  perfect  freedom  so  that  the  unsterilized  edges 
will   not   be   constantly   hit   by   the   hands. 

e.  Water. — Each   of    the   two    last-mentioned    bowls 
must  have  been  thoroughly  scrubbed  out  and  carefully 
scalded  in  boiling  water  (or  better,  boiled  in  a  large  kettle 
or  wash-boiler)    and  not  handled  by  anyone  except  the 
operator  before  using. 

In  a  private  house  somebody  must  stand  by  these 
solutions  (particularly  the  alcohol)  to  keep  flies  from 
alighting  upon  and  contaminating  them — a  matter  of 
greatest  import.  One  fly  may  upset  hours  of  work,  and 
kill  a  patient  if  unnoticed. 

Substitutes. — If  the  hands  have  not  been  in  pus 
lately  the  permanganate  and  oxalic-acid  solutions  may 
be  omitted.  In  such  case,  after  the  hands  have  been 
well  scrubbed  and  the  nails  attended  to,  turpentine  may 
be  poured  upon  them  and  rubbed  into  the  skin  and  around 
the  nails  for  at  least  two  minutes;  then  scrubbing  with 
soap  and  hot  water  proceeded  with,  and  the  alcohol  and 
sublimate  solution  employed. 

If  alcohol  cannot  be  obtained,  tincture  of  camphor 
(used  in  so  many  houses)  may  be  used,  though  not  very 
good. 

Rubber  Gloves. — The  same  care  should  be  taken 
in  efforts  to  sterilize  the  hands  when  rubber  gloves  are 
to  be  used  as  they  may  be  pricked  or  torn  at  any  moment. 
It  is  perhaps  best  that  the  operator  should  work  with- 


256  SURGICAL  THERAPEUTICS 

out  gloves,  but  it  is  desirable  that  the  assistant  shall  wear 
them  as  most  operation-infection  comes  from  the  fingers. 

OPSONIC  TREATMENT   IN  SURGERY 

Just  what  will  be  the  ultimate  results  of  the  application 
of  Wright's  theory  of  the  opsonins  to  surgical  practice 
cannot  be  foretold;  but  Ohlmacher,  of  Detroit,  gives  his 
own  experience  with  the  use  of  bacterial  vaccines,  prefer- 
ably autogenous,  in  various  surgical  conditions.  While 
not  neglecting  to  take  the  opsonic  index  when  practicable, 
he  was  compelled  to  rely  largely  on  the  clinical  manifesta- 
tions as  a  guide  to  the  repetition  and  size  of  dose,  always 
endeavoring,  of  course,  to  give  the  injections  at  the  right 
time,  when  the  positive  phase  is  beginning  to  fall,  and 
not  in  the  negative  phase. 

As  Wright  points  out,  the  great  cause  of  failure  in 
previous  tuberculin  treatment  of  tuberculosis  was  the 
giving  of  too  large  injections  and  too  frequent  repetition 
of  the  dose,  causing  a  marked  negative  phase  and  keeping 
it  up.  Ohlmacher  thinks  that  his  results  might  have 
been  better  than  they  were  had  he  been  able  to  make 
more  systematic  opsonic  determinations,  which  often  show 
a  fall  of  resistance  before  the  symptoms  indicate  it.  He 
has  had  remarkable  success  in  various  types  of  staphylo- 
coccus  infections,  obstinate  cases  of  acne  and  furunculosis, 
impetigo,  palmar  abscess,  and  in  a  very  distressing  case  of 
what  has  been  called  psoriasis,  but  which  he  thinks  was  an 
extraordinary  case  of  staphylococcic  dermatitis,  and  which 
yielded  rapidly  to  opsonic  treatment  with  an  autogenic 
culture  of  staphylococcus  aureus.  He  had  also  very  satis- 
factory results  with  a  case  of  very  annoying  bladder  infec- 
tion from  the  colon-bacillus,  similarly  treated  after  other 
treatment  had  failed. 

A  very  striking  case  was  one  of  sacculated  pneumococcus 
empyema,  in  which  perfect  recovery  occurred  in  seven 


OSTEOMYELITIS  257 

days  after  two  injections  following  a  small  puncture.  Ohl- 
macher  believes  that  even  the  generally  condemned  method 
of  aspiration  would  have  been  sufficient  in  this  case  when 
reinforced  by  opsonic  therapy.  Owing  to  delay  in  obtain- 
ing Koch's  tuberculin  R.,  the  standard  vaccine  for  tuber- 
culous cases,  his  experience  with  tuberculosis  has  as  yet 
been  limited,  but  he  has  been-  able  to  obtain  a  strain  of 
gonococcus  culture  with  which  he  has  had  striking  success 
in  the  treatment  of  gonorrhea  and  its  complications,  includ- 
ing gonorrheal  rheumatism  and  conjunctivitis.  From  what 
he  has  already  seen,  he  is  prepared  to  say  that,  with  proper 
artificial  autoinoculation,  we  can  obtain  constitutional  and 
local  improvement  in  many  subacute  and  chronic  affec- 
tions entirely  beyond  anything  previously  possible  in 
medicine. 

OSTEOMALACIA 

This  disease  has  been  temporarily  greatly  relieved  by 
ovarian  transplantation.  But  in  every  case  thus  far  re- 
ported there  has  been  a  speedy  change  for  the  worse. 

OSTEOMYELITIS 

Inflammation  of  the  bone-marrow  is  a  thing  often  for- 
gotten by  the  busy  practitioner;  a  wrong  diagnosis  is  the 
rule.  With  young  adults  particularly  the  symptoms  of 
general  infection  may  be  so  prominent  as  to  overshadow 
the  local  trouble.  Absorption  of  toxins  may  so  overwhelm 
the  patient  that  he  cannot  give  any  testimony  as  to  the 
presence  of  the  bone  affection,  and  unless  a  very  careful 
examination  is  made  the  local  lesion  may  be  overlooked, 
especially  in  parts  thickly  covered  by  muscle.  A  diagnosis 
of  delirium  tremens  has  been  made  under  these  conditions, 
when  the  subject  had  been  drinking.  The  treatment  con- 
sists in  locating  the  point  of  infection  and  boring  a  good- 
sized  hole  to  it,  with  injection  of  lo-percent  iodoform 


258  »  SURGICAL  THERAPEUTICS 

emulsion;    and    careful    antiseptic    dressings.     Internally 
opium,  quinine  and  stimulants  are  indicated. 

OZENA  TREATED  SURGICALLY 

Sondermann  recommends  treatment  of  ozena  by  the 
following  surgical  measures:  A  rubber  condom  is  intro- 
duced collapsed  into  the  nose.  It  is  then  inflated  by  a 
connecting  tube  and  bulb,  when  it  fits  closely  against  the 
walls  of  the  nose,  adapting  itself  to  all  nooks  and  crevices. 
After  from  five  to  ten  minutes  the  stopcock  is  turned  and 
the  air  allowed  to  escape  from  the  condom,  after  which  it 
is  easily  removed  and  transferred  to  a  vessel  containing 
water.  Many  of  the  crusts  stick  to  it,  while  those  remain- 
ing in  the  nose  are  loosened  and  can  be  readily  expelled 
spontaneously.  During  the  first  week  the  patient  repeats 
this  twice  a  day  and  later  once  a  day.  Th!s  procedure  is 
supplemented  by  cleaning  of  the  nose  thoroughly,  drying 
and  blowing  in  aristol  or  boric  acid  mixed  with  a  little 
antipyrin.  The  disease  is  now  regarded  as  contagious. 

PAGETS  DISEASE 

Malignant  papillary  dermatitis  (cancerous  ezcema  of 
the  nipple)  may  occur  both  in  male  and  female,  though 
usually  in  women  from  irritation  of  suckling.  It  is  essen- 
tially a  carcinoma  of  slow  development;  and  if  it  does  not 
yield  promptly  to  the  x-ray,  amputation  of  the  breast  should 
be  insisted  upon. 

PAIN 

Chloro-Phenol  for  Pain. — When  chloral  hydrate  and 
phenol  in  equal  parts  are  rubbed  together  there  is  formed 
a  syrupy  liquid  which  is  strongly  antiseptic  and  anodyne 
when  used  locally.  For  the  pain  of  inflammatory  troubles 
it  may  be  gently  rubbed  in  or  applied  on  flannel.  It  is 
especially  effective  in  the  control  of  certain  neuralgic  pains, 
notably  pleurodynia. 


PANCREATITIS  259 

Painful  HeeL — Some  patients  complain  of  pain  in 
the  heel,  most  prominent  for  a  little  while  after  getting 
out  of  bed.  It  is  often  one  of  the  sequels  of  gonorrheal 
infection.  It  may  also  be  due  to  a  calcaneobursitis  of 
traumatic  as  well  as  gonococcic  origin.  In  others  still 
there  may  be  a  small  exostosis  of  the  calcaneum,  which  also 
is  most  frequently  due  to  a  gonorrheal  infection,  possibly 
of  many  years  before.  Also  it  may  be  due  to  simple  "weak 
foot"  in  very  heavy  patients,  in  which  case  either  strapping 
or  use  of  a  brace  to  the  arch  of  the  foot  will  relieve.  But 
in  most  instances  the  "two-glass  test"  will  show  "clap- 
threads"  in  the  urine;  and  persistent  treatment  for  the 
hitherto  unsuspected  chronic  gonorrhea  will  cure  the  pain- 
ful heel  and  other  symptoms  usually  attributed  to  "rheuma- 
tism" or  "gout."  And  for  the  internal  treatment  of 
gonorrheal  "rheumatism"  it  is  a  good  thing  to  know  that 
calcium  sulphide  is  often  quickly  curative. 

Post-Operative  Pain. — The  temptation  to  use  mor- 
phine to  allay  the  pain  following  serious  operation  should 
not  be  yielded  to  save  in  extreme  cases;  morphine  locks  up 
the  secretions  and  obscures  symptoms  which  may  be  of 
importance.  For  the  ordinary  pain  one  grain  of  phosphate 
of  codeine  may  be  given  hypodermically  and  repeated 
every  four  hours  as  long  as  may  be  necessary — it  does  not 
give  rise  to  "habit"  as  does  morphine.  For  pelvic  pain  two 
grams  (30  grains)  of  antipyrin  may  be  given  with  good 
effect — dissolved  in  four  ounces  of  starch  water  and  thrown 
into  the  rectum.  If  morphine  must  be  given  it  is  least 
objectionable  in  the  "anesthetic  tablet":  morphine, gr.  1-4; 
hyoscine  hydrobromide,  gr.  i-ioo;  and  cactin,  gr.  1-67;  used 
hypodermically,  to  be  repeated  in  four  to  six  hours  if  needed. 

PANCREATITIS 

Acute  inflammation  of  the  pancreas  sometimes  demands 
surgical  intervention,  though  generally  fatal  even  when 


260  SURGICAL  THERAPEUTICS 

operated  upon.  The  pains  are  usually  localized  at  the 
epigastrium,  but  when  gallstones  are  present,  may  also  be 
situated  in  the  region  of'  the  gall-bladder  or  in  the  ileo- 
cecal  quadrant  of  the  belly.  The  attack  may  be  ushered 
in  with  an  acute  seizure  of  bilious  vomiting,  quickly  sub- 
siding, unlike  the  vomiting  of  appendicitis  and  gallstone 
colic.  The  tongue  is  dry  and  parched,  though  there  may 
be  but  a  trifling  amount  of  fever.  Obstinate  refusal  of  the 
bowels  to  move  is  a  prominent  symptom,  though  there  is 
but  moderate  distension  from  flatus.  A  peculiar  feature 
is  that,  when  the  abdominal  wall  is  thin,  the  omentum  may 
be  felt  bunched  up  at  two  or  three  points. 

The  presence  of  this  condition  without  any  signs  pointing 
directly  to  other  intraabdominal  pathological  disturbance 
should  arouse  suspicion  of  pancreatitis.  In  case  of  doubt 
it  is  better  to  give  the  patient  the  benefit  of  an  explora- 
tory section,  especially  if  there  be  a  trp,ce  of  sugar  in  the 
urine.  It  is  essential  to  remember  that  the  amount  of 
hemorrhagic  effusion  which  escapes  into  the  abdominal 
cavity  in  some  cases  and  the  extent  of  the  fat  tissue-necrosis 
are  not  responsible  for  the  fatal  outcome.  Death  is  evi- 
dently due  to  absorption  of  poisons  from  the  diseased  pan- 
creas, and  the  tension  in  the  retroperitoneal  tissue  around 
the  pancreas  evidently  promotes  absorption.  This  fact 
must  be  borne  in  mind  in  operating,  and  provision  must 
be  made  for  reducing  the  tension  and  for  improving  the 
condition  of  the  circulation  through  the  gland.  By  this 
means  it  may  be  possible  to  check  the  poisoning  of  the 
organism  from  the  decomposing  gland  by  exposing  and 
draining  it  directly.  It  is  also  possible  that  immunization 
with  trypsin  may  prove  effectual  in  acute  pancreatitis. 

PARALYSIS:  POST-OPERATIVE 

Following  an  operation  of  more  than  an  hour's  duration 
there  may  be  temporary  paralysis  of  one  arm.  Some  authors 


PERICARDITIS  261 

have  attributed  this  to  the  deleterious  effect  of  chloroform; 
but  it  occurs  after  ether  narcosis  and  also  as  a  postopera- 
tive accident  in  anesthesia  produced  by  the  hyoscine- 
morphine-cactin  combination.  It  is  due  entirely  to  the 
position  of  the  arm;  by  reason  of  the  entire  weight  of  the 
arm  (and  occasionally  a  considerable  part  of  the  thorax) 
being  thrown  across  the  sharp  edge  of  the  operation- 
table,  pressure-paralysis  is  induced,  just  as  one's  foot  "goes 
to  sleep"  when  the  thigh  hangs  over  the  rail  of  a  chair. 
It  lasts  from  a  few  hours  to  as  much  as  two  or  three  weeks. 
If  the  patient  becomes  anxious  about  it,  massage  may  be 
ordered  or  the  faradic  current  may  be  applied  (not  because 
it  possesses  any  value  but  that  the  patient  may  feel  that 
something  is  being  done).  In  persistent  cases  the  galvanic 
current  may  be  used  with  intramuscular  injections  of  one- 
thirtieth  grain  of  sulphate  of  strychnine  once  daily. 

PERICARDITIS 

Pericarditis  becomes  a  surgical  disease  when  the  effusion 
becomes  so  great  that  there  is  serious  interference  with  the 
heart's  action,  and  when  the  serum  becomes  infected  by 
pyogenic  bacteria.  Before  making  an  attempt  to  remove 
the  effusion  the  patient  should  be  given  a  big  drink  of 
whisky,  and  a  quarter  grain  of  morphine  with  i-ioo  grain 
hyoscine  hypodermically.  The  skin  must  be  as  thoroughly 
cleaned  as  for  the  most  serious  operation  and  the  needle 
must  be  taken  directly  from  the  boiler.  Five  minutes  before 
operation  a  little  of  a  2-percent  solution  of  cocaine  should 
be  injected  beneath  the  skin  and  into  the  muscle.  In 
aspirating,  the  needle  may  be  introduced  through  the  eighth 
intercostal  space;  or  if  the  diaphragm  be  displaced  down- 
ward strongly  the  puncture  may  be  made  just  to  the  left 
of  the  ensiform.  On  account  of  the  danger  of  wounding 
the  heart  as  the  pericardium  contracts  it  is  better  to  use 
a  small  trocar  and  canula  rather  than  a  sharp  needle. 


262  SURGICAL  THERAPEUTICS 

The  fluid  should  be  permitted  to  escape  very  slowly.  When 
the  pericardium  is  full  of  pus,  excision  of  rib,  free  incision 
and  drainage  offer  the  only  escape  from  death  by  sepsis. 

PERIOSTITIS:    CHRONIC 

Chronic  thickening  of  the  periosteum  positively  known 
to  be  non-syphilitic  in  origin  will  often  yield  to  small  doses 
of  potassium  iodide,  one  gram  (fifteen  grains)  three  times 
a  day.  It  is  best  given  in  compound  syrup  of  trifolium  or 
simple  elixir. 

PERITONITIS 

Acute  peritonitis  is  always  due  to  direct  infection  with 
pyogenic  microorganisms,  as  from  a  leaking  appendix, 
a  perforated  gall-bladder  or  other  viscus,  a  ruptured  pus- 
tube,  etc.  The  disease  can  be  cured,  then,  by  immediate 
removal  of  the  cause,  with  drainage.  The  following  points 
are  of  importance:  (i)  Acute  general  peritonitis  can  be 
cured  by  operative  means,  provided  it  is  recognized  early. 
(2)  Early  recognition  is  aided  by  a  knowledge  of  the 
etiology  of  the  disease,  and  accurate  observation  of  the 
patient's  symptoms,  local  and  general.  (3)  On  examina- 
tion of  the  patient  the  most  important  early  signs  of  perito- 
nitis are  localized  pain,  becoming  general,  muscular  rigidity, 
rapid  and  increasing  pulse-rate,  and  rising  temperature. 
(4)  Early  diagnosis  should  be  followed  by  prompt  opera- 
tive treatment,  as  this  offers  in  most  cases  the  only  chance 
for  recovery.  To  relieve  pain,  until  operation  can  be  done, 
phosphate  of  codeine  may  be  given,  hypodermically,  as 
often  as  needed,  in  half-grain  doses. 

For  Pain  of  Peritonitis. — To  control  the  pain  of  the 
adhesive  peritonitis,  which  often  saves  the  patient's  life  in 
appendicitis,  as  well  as  that  of  the  postoperative  form, 
aconitine  is  of  much  value.  Opium  in  every  form  does 
harm,  though  sometimes  a  grain  of  phosphate  of  codeine 


PERITONITIS  263 

has  to  be  given;  but  little  will  be  needed  if  a  half  milligram 
of  aconitine  every  hour  be  given  until  the  pulse  is  soft 
and  the  fever  lowered. 

Tuberculous  Peritonitis. — Concerning  this  condition 
it  may  be  said:  (i)  The  exciting  cause  of  tuberculous 
peritonitis  is  the  bacillus  tuberculosis.  (2)  This  disease 
occurs  most  frequently  between  the  ages  of  twenty  and 
forty,  and,  according  to  clinical  experience  at  least,  is  more 
common  in  females  than  in  males.  (3)  It  is,  in  the  great 
majority  of  cases,  secondary  to  a  tuberculous  focus  in  some 
other  part  of  the  body,  most  frequently  the  lungs.  (4) 
There  seems  to  be  no  doubt  that  infection  through  the 
fallopian  tubes  may  occur,  but  its  frequency  is  disputed. 
(5)  The  onset  of  the  disease  is  usually  slow  and  insidious 
and  its  clinical  course  presents  few  definite  or  characteristic 
symptoms.  (6)  The  diagnosis  is  generally  difficult,  and 
is  often  not  made  until  operation  or  autopsy.  (7)  The 
prognosis  in  the  ascitic  form  of  the  disease  is  comparatively 
good,  if  treated  by  abdominal  section,  and  in  the  non-exu- 
dative variety  bad.  In  any  form  it  is  of  course  corresponding- 
ly modified  by  the  existence  of  tuberculous  disease  in  other 
parts  of  the  body.  (8)  The  treatment  in  most  cases  should 
be  operative,  consisting  in  laparotomy,  with  removal  of 
the  fallopian  tubes  when  practicable.  (9)  No  satisfac- 
tory explanation  has  as  yet  been  offered  as  to  the  reason 
for  the  cure  which  so  often  follows  operative  treatment 
in  this  disease.  (10)  Very  soon  after  the  abdominal 
section  a  general  antituberculosis  treatment  should  be 
adopted  with  special  attention  to  proper  diet  and  out-door 
life. 

We  have  been  taught  to  believe  that  simple  abdominal 
section  with  considerable  manipulation  of  the  viscera  and 
evacuation  of  the  ascitic  fluid  will  cure  tuberculous  peri- 
tonitis. But  while  it  is  true  that  certain  patients  have 
apparently  been  cured  by  such  mild  procedures,  a  much 


264  SURGICAL  THERAPEUTICS 

larger  number  have  gone  on  to  fatal  termination.  The 
mistake  has  been  made  of  treating  a  symptom  (ascites) 
instead  of  the  disease.  Radical  removal  of  every  local 
deposit  of  tubercle  wherever  found  is  the  only  certain  cure. 
In  a  small  percentage  of  cases  it  cannot  be  found;  here  the 
only  resource  is  irrigation,  manipulation  and  closure.  In 
a  larger  percentage  of  cases  the  lesions  are  so  numerous  or 
so  situated  that  they  cannot  be  removed;  here  gentle  rub- 
bing of  the  affected  surfaces  with  gauze  may  do  good.  In 
all  cases,  whether  the  local  focus  be  removed  or  not,  the 
most  energetic  constitutional  treatment  must  be  instituted: 
forced  feeding  and  tonics  do  fully  ^as  much  in  abdominal 
tuberculosis  as  in  pulmonary.  But  unless  the  primary 
seat  of  the  disease  is  found  and  the  source  of  trouble  re- 
moved, a  guarded  prognosis  should  be  given  regardless  of 
how  much  the  patient  may  gain  after  operation.  Medica- 
tion is  the  same  as  that  for  any  other  abdominal  section 
during  the  first  few  days,  and  then  the  same  as  for  phthisis. 

When  operation  is  declined,  or  is  contraindicated,  the 
abdomen  may  be  smeared,  twice  a  day,  with  this  oint- 
ment: 

Yellow  mercuric  oxide    1.5  (grs.  20) 

Belladonna  ointment     32.0  (oz.      i) 

Lanolin 32.0  (oz.      i) 

This  relieves  the  pain  to  a  remarkable  degree,  especially 
with  children  in  whom  the  skin  is  sufficiently  thin  and 
tender  to  permit  free  absorption. 

PHLEBITIS 

Immobilization  of  the  extremity  affected  should  be  the 
rule  for  a  much  longer  period  than  generally  advised, 
especially  in  thrombosis  of  the  femoral  vein.  Massage  ought 
not  to  be  begun  before  one  month  after  the  last  rise  of  the 
temperature;  tarsal  and  metatarsal  articulations  will  be  first 
mobilized,  later  larger  joints.  Only  gentle  massage  will 


PLEURITIS  265 

be  resorted  to  and  the  patient  progressively  trained  to 
resume  the  standing  position. 

PLEURITIS 

Pleurisy  becomes  a  surgical  disease  as  soon  as  it  is 
apparent  that  the  effusion  is  not  being  absorbed  or  that  the 
serum  is  infected  with  pyogenic  bacteria.  When  it  is 
decided  that  the  serum  accumulated  in  the  pleura  is  to  be 
evacuated  the  skin  must  be  scrubbed  carefully  with  soap 
and  water;  a  few  drops  of  cocaine  are  then  to  be  injected 
beneath  the  skin  and  into  the  intercostal  muscles,  but  not 
into  the  pleura;  a  large  aspirator-needle  is  boiled  for  at 
least  ten  minutes;  the  skin  is  pulled  a  little  upward  or 
downward  and  from  over  an  intercostal  space  and  the 
needle  thrust  quickly  and  directly  into  the  pleural  space. 
A  boiled  stilet  must  be  at  hand  to  push  through  the  needle 
from  time  to  time  if  it  become  clogged  by  flakes  of  lymph. 
The  fluid  must  be  allowed  to  escape  slowly  so  that  the  lung 
may  expand  (if  adhesions  have  not  formed). 

When  all  has  been  withdrawn  the  needle  is  taken  out 
by  a  short,  quick  jerk  and  the  skin  allowed  to  slip  over 
the  opening.  A  little  piece  of  gauze  may  be  placed  over 
the  skin-puncture  and  held  in  place  by  a  strip  of  adhesive 
plaster. 

When  pus  is  present  the  operation  of  choice  for  child- 
ren is  the  Estlaender:  removal  of  a  small  part  of  one  rib, 
or  even  a  mere  slit  in  the  parietal  pleura  sometimes  effect- 
ing a  perfect  cure  if  the  subsequent  dressings  be  made 
with  sufficient  care  as  to  asepsis;  for  adults  the  Schede 
operation  (excision  of  the  chest -wall  including  the  parietal 
pleura,  over  at  least  one-third  of  the  entire  side  affected) 
is  the  only  one  which  promises  complete  cure,  since  it 
permits  the  skin  and  muscles  to  fall  in  on  the  visceral 
pleura  and  so  obliterate  the  huge  pus-sac.  It  is  remarkable 
how  much  the  lung  will  expand  after  such  a  formidable 


266  SURGICAL  THERAPEUTICS 

operation.     The  most  energetic  antituberculous  and  tonic 
treatment  must  be  kept  up  for  months. 

POULTICES 

Charcoal  Poultices. — Charcoal  poultice,  like  all 
other  poultices,  has  fallen  into  disuse  on  account  of  the 
nastiness,  other  and  better  agents  being  employed;  but 
sometimes  patients  are  found  who  demand  poultices,  and 
when  there  is  an  ugly  sloughing  (and  especially  a  sloughing 
old  wound  or  ulcer)  the  charcoal  poultice  may  be  ordered. 
It  possesses  the  advantage  of  being  a  powerful  deodorant, 
and  sometimes  it  does  seem  to  do  more  good  at  the  begin- 
ning of  treatment  of  such  ulcers  than  the  modern  "anti- 
septic" applications.  It  should  be  made  thus:  Wood 
charcoal,  pulverized,  one-half  ounce,  divided  in  two  parts; 
bread-crumbs,  two  ounces;  linseed  meal,  one  ounce  and  a 
half;  boiling  water,  ten  ounces.  The  breadcrumbs  and 
linseed  meal  are  macerated  for  ten  minutes  with  heat  to 
keep  the  mass  just  below  boiling,  and  then  half  of  the 
charcoal  is  stirred  in  and  one-half  ounce  of  liquid  phenol 
added,  care  being  taken  that  it  be  well  mixed.  The  poul- 
tice is  then  spread  on  a  cloth,  the  remaining  half  of  the 
charcoal  sprinkled  on  and  the  mass  applied  quickly  to  the 
sore  and  covered  with  a  piece  of  oil-cloth  or  rubber-tissue. 

Soap  Poultices  in  Suppuration. — When  there  is 
much  pain  from  a  suppurative  process,  like  periostitis, 
adenitis,  abscess  or  forming  whitlow,  much  comfort  may 
be  obtained  from  application  of  a  soap  poultice.  Several 
thicknesses  of  gauze  are  saturated  with  soft  soap — the 
green  soap,  ethereal  soap  or  potash  soap  of  the  U.  S.  P. 
is  best — and  applied  to  and  around  the  affected  area  and 
covered  with  rubber-tissue  or  oiled  silk,  held  in  place  by 
bandages.  Better  is  a  mixture  of  soap  and  alcohol: 

Green  soap 2  parts 

Alcohol i  part 


PROSTATECTOMY:     INDICATIONS  FOR  267 

This  is  to  be  applied  in  the  same  way  and  should  be 
allowed  to  remain  all  night.  It  is  also  a  good  mixture  to 
be  used  in  acute  synovitis.  It  is  not  a  good  thing  to  apply 
to  a  wounded  or  granulating  surface  as  the  alkali  is  too 
irritating. 

PROCTITIS:    ACUTE 

An  acute  irritation  of  the  rectum  is  sometimes  followed 
by  a  painful  condition  associated  with  discharge  of  mucus. 
Acute  rectal  catarrh  this  state  of  affairs  is  called  by  the  older 
pathologists.  Severe  tenesmus  with  mucous  diarrhea  accom- 
panies it,  persisting  for  several  days  if  left  alone.  An  injec- 
tion of  a  solution  of  chlorate  of  potassium  is  best  for  this: 

Potassium  chlorate 6.0  (grs.  90) 

Water 128.0  (ozs.    4) 

This  should  be  slightly  warmed  and  thrown  into  the  rec- 
tum. There  will  be  some  expulsive  efforts  at  first  but  the 
clyster  must  be  retained  twenty  minutes  if  possible.  It 
may  be  used  twice  a  day,  but  two  or  three  injections  usually 
suffice. 

PROSTATECTOMY:    INDICATIONS  FOR 

The  question,  When  should  the  prostate  be  removed? 
is  thus  answered  by  John  B.  Murphy: 

1.  Prostatic  enlargement  to  a  pathological  degree. 

2.  Painful  and  frequent  urination. 

3.  As  a  cure  for  catheter  life. 

4.  As  a  cure  for  secondary  cystitis. 

5.  For  the  relief  of  pressure  on  the  rectum. 

6.  Priapism  in  the  aged  with  perineal  irritation. 
Goodfellow  declares  that  "there  are  no  contraindications 

to  the  operation  unless  the  condition  of  the  patient  is  such 
that  no  operation  of  any  kind  is  warranted," 


268  SURGICAL  THERAPEUTICS 

PROSTATIC  HYPERTROPHY  AND  STONE 

That  there  is  a  decided  relation  between  stone  in  the 
bladder  and  hypertrophy  of  the  prostate  is  the  claim  of 
Prof.  Reginald  Harrison,  of  London.  He  says  the  explana- 
tion is  this:  (i)  The  enlarged  prostate  forms  a  hindrance 
to  the  spontaneous  exit  of  small  stones  of  urates  or  oxa- 
lates  that  are  formed  in  the  kidneys  in  old  age.  (2)  The 
difficult  micturition,  and  the  ammoniacal  disintegration 
of  the  urine,  can  lead  to  cystitis  and  the  formation  of  phos- 
phatic  concretions.  (3)  Litholapaxy  does  not  accomplish 
the  result  desired.  Only  removal  of  the  prostate  at  the 
time  the  stone  is  excised  will  effect  a  perfect  cure.  Har- 
rison prefers  the  suprapubic  method,  which  makes  possible 
the  removal  of  the  stones,  with  prostatectomy. 

PROSTATORRHEA:    HYOSCYAMINE  FOR 

Prostatorrhea  with  irritable  deep  urethra  may  be  greatly 
benefited  by  the  internal  use  of  hyoscyamine.  One  quarter 
of  a  milligram  (0.00025,  or  I"25°  gram)  m  granule  form 
may  be  ordered  four  times  a  day,  either  alone  or  with 
one  centigram  (1-6  grain)  of  concentrated  hydrastin.  If 
there  be  scanty  urination  much  water  must  be  drunk  and 
barosmin  (the  resinous  product  of  buchu)  be  taken  in  doses 
of  one  milligram  three  times  a  day. 

PRURITUS  ANI 

Nearly  all  cases  of  persistent  itching  of  the  anus  may 
be  traced  to  one  of  these  causes:  (i)  The  most  common 
is  superficial  ulceration  or  abrasions  of  the  anal  canal. 
(2)  Next,  catarrhal  diseases  of  the  rectal  mucosa  which 
cause  discharge  from  the  anus.  (3)  External  hemor- 
rhoids or  skin-tags  which  prevent  proper  cleansing  of  the 
parts.  (4)  Small  polyps  of  the  anal  canal,  protruding 
internal  hemorrhoids,  prolapse  and  fissures,  etc.  The 


PYLORIC  STENOSIS:  SURGICAL  TREATMENT     269 

treatment  consists  (in  addition  to  removing  the  cause)  in 
restoring  the  altered  perianal  skin  to  the  normal.  For 
this  purpose  nitrate  of  silver  followed  by  citrine  oint- 
ment are  the  best  applications. 

Prescriptions  for  Pruritus  Ani. — Cowles  recom- 
mends the  following  formulas: 

Ungt.  hydrargyri   ammoniat..     1.6  (grs.  25) 

Adipis  benzoinati 30.0  (oz.      i) 

M.    Sig.:     Apply  locally  as  directed,  or 

Hydrargyri  chloridi  mitis    8.0  (drs.    2) 

Sig.:  Use  locally  as  a  dusting  powder  as  directed. 
If  there  is  much  thickening  of  the  skin  surrounding  the  anus 
some  preparation  of  salicylic  acid  should  be  used,  for 
example : 

Acidi  carbolici i.    (grs.    15) 

Acidi  salicylici 0.6  (grs.    10) 

Ichthyoli 1.6  (min.  25) 

Petrolati    30.0  (oz.       i) 

M.    Sig.:     Apply  locally  as  directed. 
A  hot  sitz-bath  or  the  application  of  hot  compresses  often 
confers  immediate  relief.     The  following  formula  is  recom- 
mended by  Morris: 

Acidi  carbolici    1.5  (grs.  22) 

Cocainae  hydrochloridi 0.6  (grs.  10) 

Petrolati    30.    (oz.      i) 

M.  Fiat  unguentum.  Sig.:  Apply  locally  as  directed. 
Caution  should  be  taken  not  to  allow  its  use  long  enough 
to  induce  the  cocaine  habit. 

PYLORIC  STENOSIS:  SURGICAL  TREATMENT 

Socalled  idiopathic  dyspepsia  is  comparatively  rare; 
functional  dypepsia  and  indigestion  have  their  origin  quite 
commonly  in  a  narrowing  of  the  pylorus,  which  interferes 
with  normal  drainage  of  contents.  This  narrowing  is 
sometimes  congenital,  but  more  often  due  to  cicatricial 


270  SURGICAL  THERAPEUTICS 

contracture  following  the  healing  of  pyloric  ulcer.  Of  late 
it  is  being  found  that  duodenal  ulceration  is  not  uncommon 
— either  independent  of  or  associated  with  pyloric  ulcer. 
Ulceration  being  the  most  common  of  the  causes  of 
obstruction  from  within,  so  likewise  are  adhesions 
the  most  frequent  exciting  factor  from  the  outside 
of  the  lumen.  These  may  be  caused  by  localized  perito- 
nitis, due  to  gall-bladder  infections,  pancreatitis,  etc.  The 
result  upon  the  stomach  of  outlet  stenosis  depends  upon  its 
completeness.  It  is  most  often  the  symptom-syndrome  of 
indigestion,  and  extends  over  many  years'  duration,  grow- 
ing ever  progressively  worse.  Putrefaction  of  stomach- 
contents  and  dilation  and  atony  are  among  the  later  mani- 
festations. So  likewise  is  a"  residuum. 

The  predisposition  of  ulcer  to  ultimate  cancer-formation 
— the  socalled  cancer  on  an  ulcer  base — is  great.  The 
treatment  of  this  condition  is  essentially  surgical,  and  is 
to  be  summed  up  in  the  one  word,  "drainage."  Medi- 
cines are  of  use  only  as  they  act  as  antiseptics  on  the 
fermenting,  putrifying  stomach-contents,  and  thus  control, 
to  a  degree,  putrefaction  and  fermentation  with  consequent 
gas-formation  and  stomach-distension.  Muscular  power 
of  the  stomach  is  insufficient  to  force  a  normal  food-supply 
through  the  narrowed  outlet,  so  muscle  excitants  and  tonics 
are  of  no  avail.  Lavage  is  superior  to  medication  of  any 
kind.  This  may  be  dangerous  in  the  stage  of  acute  ulcera- 
tion. The  best  operation  is  a  posterior  gastroenterostomy 
without  loop  and  with  suture.  There  being  no  loop  of 
jejunum,  and  the  stomach  being  tapped  at  its  lowest  point, 
there  is  very  little  danger  of  establishment  of  a  "vicious 
circle,  "  and  an  enterostomy  is  unnecessary,  and  with  this 
latest  technic  is  quite  impossible.  The  two  organs,  stomach 
and  jejunum,  are  anastomosed  at  the  point  where  they 
normally  lie  almost  in  contact.  Too  strong  a  plea  cannot 
be  made  for  early  rather  than  late  operations. 


RECTUM  271 

PYURIA 

When  the  flow  of  pus  is  excessive  in  suppurative  pyelitis 
as  well  as  when  excessive  amounts  of  albumin  are  passed 
in  nephritis,  a  marked  diminution  may  be  produced  by  arbu- 
tin,  the  glucosidic,  active  principle  of  uva  ursi — a  drug  for 
long  used  in  crude  forms  as  a  diuretic  and  tonic  to  mucous 
membranes.  The  dose  is  from  one  to  five  grains  every 
two  or  three  hours. 

RECTUM 

Cathartics  in  Prolapsus  Recti. — After  the  rectum 
has  been  returned  beyond  the  sphincter  the  question  arises, 
"what  is  the  best  way  to  move  the  bowels?"  for  straining 
at  stool  is  the  cause  of  the  prolapse  and  may  induce  its 
immediate  return.  Podophyllin  in  doses  of  one  milligram 
(gr.  1-67)  every  hour,  six  times,  will  cause  very  gentle  move- 
ments without  straining.  Two  or  three  tablets  should  be 
given  at  bedtime  for  a  week  or  more. 

Examination  in  Rectal  Surgery. — Brickner  very 
aptly  says :  Don't  fail  to  make  a  digital  rectal  examination 
in  cases  of  appendicitis  and  in  all  ailments  when  the  diag- 
nosis is  obscure.  Nor  should  it  ever  be  omitted  before  an 
operation  upon  anal  disorders.  It  may  save  the  embarass- 
ment  of  a  subsequent  discovery  that  a  patient's  hemor- 
rhoids, for  example,  were  but  an  expression  of  a  carcinoma 
higher  up  in  the  rectum. 

Local  Anesthesia  in  Rectal  Work. — The  technic 
advised  by  Tuttle  consists  in  anesthetizing  the  lesser  sphinc- 
terian  nerve  of  Morestin  and  the  inferior  hemorrhoidal 
nerve  by  a  single  puncture  of  the  hypodermic  needle  back 
of  the  posterior  anal  commissure,  and  introduction  of 
from  20  to  30  minims  of  o. 5-percent  eucaine  or  cocaine  solu- 
tion so  that  the  sphincter  can  be  thoroughly  stretched.  After 
this  is  done  the  hemorrhoids,  or  other  conditions  upon  which 
operation  is  proposed,  are  anesthetized  by  the  local  injec- 


272  SURGICAL  THERAPEUTICS 

tion  of  small  quantities  of  one-tenth-percent  solution  of 
eucaine,  cocaine,  stovaine  or  novocaine.  Sometimes  it 
is  necessary  in  very  sensitive  patients  to  anesthetize  the 
branch  of  the  pubic  nerve  which  supplies  the  sphincter  at 
the  anterior  commissure  by  the  introduction  of  small  quan- 
tities of  the  solution  at  this  point. 

Prolapse  of  the  Rectum. — When  it  is  found  that 
protrusion  of  the  rectum  is  accompanied  by'  a  pocket 
of  peritoneum  so  that  excision  is  highly  dangerous, 
one  may  resort  to  ventral  fixation  of  the  sigmoid — 
colopexy,  as  it  has  been  called.  About  75  percent  of 
all  cases  may  thus  be  cured;  and  in  safe  hands  there 
is  no  mortality.  The  technic  is,  briefly,  as  follows: 
After  proper  sterilization  of  hands,  instruments,  dressings 
and  field  of  operation,  an  inci3ion  is  made,  parallel  to  and 
about  one  inch  above  Poupart's  ligament.  The  pelvic 
colon  is  recognized  and  drawn  up  until  the  prolapsed  rec- 
tum is  reduced  and  the  anus  resembles  a  funnel-like  depres- 
sion. The  lowermost  portion  is  chosen  as  the  point  of 
fixation  to  the  abdominal  wall.  An  oval  piece  of  the  parietal 
peritoneum  is  removed  in  the  iliac  fossa  and  the  colon  is 
sutured  to  the  two  edges  of  the  peritoneum  by  3o-day 
chromicized  catgut  suture.  At  the  lower  portion  of  the 
external  margin,  the  superficial  muscle-fibers,  iliac  fascia 
and  the  peritoneum  are  united  to  the  colon,  the  inner  suture 
attaching  the  colon  along  its  mesenteric  border.  The 
abdominal  wound  is  closed  without  drainage. 

Rectum:  Prolapse  of. — In  Van  Buren's  method 
the  patient  is  anesthetized  and  the  smallest  tip  of  a  Paque- 
lin  cautery  (heated  only  to  a  dull-red)  is  drawn  over  the 
entire  length  of  the  prolapsed  gut,  just  burning  through 
the  mucous  membrane.  Five  or  six  grooves  are  to  be 
burned,  parallel  to  each  other.  The  mass  is  then  pushed 
well  above  the  sphincter,  and  the  sphincter  burned  at  two 
points  on  opposite  sides  well  into  the  substance  of  the 


RECTUM  273 

muscle.  Finally  the  rectum  is  packed  with  iodoform  gauze 
which  is  removed  on  the  third  or  fourth  day. 

Retro-Rectal  Abscess. — An  abscess  forming  behind 
the  rectum  is  best  opened  by  a  semicircular  incision  between 
the  anus  and  coccyx.  This  should  be  as  free  as  the  situa- 
tion will  permit  without  cutting  the  sphincter.  When  evacu- 
ated the  cavity  should  be  mopped  out  with  absorbent  cotton 
and  loosely  packed  with  gauze.  This  should  be  removed 
daily  and  the  wound  washed  out  with  some  mild  antiseptic 
solution.  It  is  essential  that  the  sphincter  ani  be  choroughly 
stretched  at  the  time  of  operation.  Should  granulation 
be  slow  it  may  be  stimulated  by  use  of  iodoform  as  a  dust- 
ing powder,  or  by  daily  application  of  balsam  of  Peru. 

Treatment  of  Non-Malignant  Strictures  of  the 
Rectum. — When  it  is  found  that  " chronic  diarrhea"  or 
"chronic  dysentery"  depends  upon  non-malignant  stricture 
the  proper  treatment  is  that  outlined  best  by  Kelly: 
enforced  rest,  nutritious  and  non-irritating  diet,  keeping 
the  upper  bowel  emptied,  cleansing  solutions  of  mild 
antiseptics,  healing  applications  and  packs.  A  stricture  of 
moderate  caliber  may  be  cured  by  gradual  dilation  with 
bougies;  by  the  elastic  pressure  of  a  rubber  bag,  distending 
by  air  and  made  to  distend  in  a  uniform  manner  by  a  silk 
covering  (Sweetnam's  plan),  and  by  digital  distension  and 
massage.  If  a  contracting  bowel  is  watched  and  thus 
treated,  the  patient  may  go  on  for  a  long  time,  for  years 
even,  in  great  comfort,  though  the  disease  is  not  cured  and 
patients  should  be  told  so. 

However,  in  really  bad  cases  resection  is  necessary  and 
may  be  practised  even  when  the  disease  extends  over  an 
area  as  long  as  20  cm.  A  posterior  incision  with  the 
removal  of  the  coccyx,  and  sometimes  of  the  last  sacral 
vertebra,  with  the  preservation  of  the  anal  sphincters  and 
ampulla  when  possible,  and  an  end-to-end  anastomosis  of 
the  bowel,  is  the  best  procedure.  It  is  sometimes  worth 


274  SURGICAL  THERAPEUTICS 

4 

while  in  the  attempt  to  save  the  bowel,  when  the  local 
process  persists  in  advancing,  to  make  an  artificial  anus 
completely  diverting  the  fecal  current.  The  bowel  may  then 
heal  and  the  extensive  surrounding  inflammation  undergo 
resolution,  when  after  months  (or  a  year  or  more),  and 
generally  after  a  successful  resection,  the  artificial  anus 
may  be  closed  by  abdominal  section. 

In  a  high  grade  of  tuberculous  or  syphilitic  stricture, 
when  an  extensive  area  is  involved,  it  is  often  best  to  make 
an  artificial  anus  and  extirpate  the  diseased  bowel.  Kelly 
prefers  to  do  this  by  amputating  the  bowel  above  first, 
and  ligating  such  hemorrhoidal  vessels  of  the  lower  end 
as  are  within  reach,  and  then  to  complete  the  extirpation 
from  below  by  an  incision  from  sacrum  to  anus.  Advanced 
tuberculosis  always  demands  extirpation,  and  syphilis  calls, 
of  course,  for  persistent  specific  treatments  in  addition  to 
whatever  local  means  may  be  employed. 

What  Shall  We  Do  for  Cancer  of  the  Recttim?— 
This  is  a  question  every  physician  is  liable  to  have  to  ans- 
wer, one  of  great  importance  to  the  patient,  and  one  upon 
which  surgeons  have  not  yet  agreed.  From  my  own  work 
I  am  satisfied  as  to  the  justifiability  of  operating  in  every 
case  that  is  not  so  far  advanced  as  to  be  regarded  upon 
the  brink  of  the  grave.  There  can  be  no  question  that  if 
recognized  early  and  properly  removed,  carcinoma  of  the 
rectum  can  be  cured.  The  method  of  extirpation  is  a  mat- 
ter of  selection,  to  accord  with  the  surgeon's  predilection 
and  the  nature  and  stage  of  each  particular  case.  It  is 
sufficient,  however,  for  the  average  physician  to  recognize 
the  fact  that  cancer  of  the  rectum  is  not  an  absolutely  hope- 
less condition,  so  far  as  life  is  concerned.  Furthermore, 
he  should  know  and  explain  to  the  subject  of  the  disease 
that  even  if  the  neoplasm  does  recur,  life  will  have  been 
prolonged  from  one  to  four  years  and  much  suffering  have 
been  saved.  For  even  in  very  advanced  cases  it  is  best 


RICKETS  275 

to  make  an  inguinal  colotomy,  inverting  the  lower  end  of 
the  gut  and  dropping  it  into  the  pelvis,  so  as  completely  to 
prevent  the  passage  of  feces  over  the  inflamed  and  sensitive 
surface  at  the  site  of  ulceration.  By  so  doing  the  comfort 
of  the  patient  may  be  enhanced  and  life  prolonged  at  least 
a  year.  And  as  now  performed  inguinal  colostomy  is  prac- 
tically without  danger.  If  really  necessary  it  can  be  done 
under  cocaine  anesthesia. 

RESPIRATORY  FAILURE:  STRYCHNINE  FOR 

During  or  at  the  termination  of  operations  of  great 
magnitude  entirely  too  much  strychnine  is  being  given 
everywhere ;  it  is  not  at  all  uncommon  to  see  a  half  centigram 
(1-15  grain)  injected  at  one  time — for  "heart-failure." 
Strychnine  should  not  be  given  with  the  object  of  correcting 
heart-failure ;  it  is  a  stimulant  to  the  respiratory  center  and 
should  be  given  when  the  breathing  is  shallow  and  too  slow. 
It  is  therefore  especially  indicated  in  anesthesia  from  the 
hyoscine-morphine-cactin  tablet  when  the  number  of  respir- 
ations falls  below  six  per  minute.  It  should  not,  however, 
be  given  until  the  end  of  operative  work,  whenever  possible, 
as  it  is  apt  to  cause  the  patient  to  become  nervous  and 
somewhat  excited. 

RICKETS 

There  being  in  this  interesting  disease  of  early  child- 
hood a  deficiency  of  the  elements  which  should  enter  into 
the  formation  of  bones — that  is  a  "bone-salt  starvation" 
the  great  indication,  aside  from  proper  food,  is  to  supply 
the  deficiency.  Zinc  phosphide  is  highly  praised ;  from  one 
milligram  to  one  centigram  (gr.  1-67  to  gr.  1-6)  should  be 
given  three  times  a  day,  according  to  age  and  the  way 
it  is  borne. 

In  rickets  there  is  always  a  tendency  of  the  digestive 
apparatus  to  fail  in  its  function,  so  great  care  must  be 


276  SURGICAL  THERAPEUTICS 

exercised  not  to  give  zinc,  lime,  etc.,  in  doses  too  large  to  be 
accepted  by  the  stomach  and  bowels  without  irritation. 
The  syrup  of  the  lactophosphate  of  lime  is  a  most  praise- 
worthy preparation;  but  some  children  cannot  take  it  for 
any  great  length  of  time ;  it  may  be  tried  in  doses  of  a  half 
teaspoonful  thrice  daily  with  a  child  of  two  or  three  years. 
On  account  of  this  tendency  to  stomachic  irritation,  too, 
codliver  oil  cannot  often  be  given,  though  the  most  eminent 
authorities  advise  it ;  rich  cream  does  better;  when  anemia 
is  marked  and  there  are  evidences  of  tuberculosis  (formerly 
called  "scrofula")  forced  feeding  may  be  necessary,  with 
the  exhibition  of  syrup  of  the  iodide  of  iron,  one  drop  three 
times  a  day  being  better  than  larger  dosage. 

If  there  is  the  slightest  tendency  to  constipation  (as 
when  the  patient  is  taking  iron)  laxatives  must  be  ordered 
at  bedtime,  preferably  sodium  phosphate.  Phosphorus 
(or  the  phosphates)  must  be  given  freely  on  account  of  the 
influence  phosphorus  has  upon  the  growth  of  bones.  One 
or  two  decigrams  of  phosphate  of  lime  (i  to  3  grains) 
may  be  given  in  milk  three  times  a  day  without  the  knowl- 
edge of  the  child.  The  phosphates  of  iron  and  strychnine, 
each  in  1-67  grain  dose,  are  both  very  valuable.  Baths, 
followed  by  massage,  are  excellent,  but  care  must  be  exer- 
cised not  to  bathe  the  patient  too  frequently  since  hot 
baths  weaken  to  a  marked  degree,  and  in  these  cases  every 
energy  must  be  directed  toward  building  up  the  patient. 
If  there  be  a  marked  tendency  to  bending  of  the  legs,  the 
little  patient  must  be  kept,  as  much  as  possible,  from  walk- 
ing. Out-door  life  is  indispensable;  and  good  food  also. 

RODENT  ULCER 

This  form  of  malignant  disease  may  sometimes  be  cured 
by  electric  treatment — which  ought  to  be  tried  before  more 
serious  measures  are  adopted.  The  treatment  can  be  car- 
ried out  with  an  ordinary  portable  galvanic  (not  faradic) 


RUBBER  GLOVES:  MURPHY'S  SUBSTITUTE        277 

battery.  The  process  is  based  on  the  principle  of  the  intro- 
duction of  the  zinc  ions  into  the  tissues  of  the  ulcer  by 
means  of  a  continuous  current.  By  this  plan  the  ulcer  is 
made  to  assume  the  appearance  of  an  ordinary  simple 
sore,  and  in  many  instances  it  is  healed  in  a  few  weeks 
after  a  single  application.  An  ordinary  medical  contin- 
uous-current battery,  with  a  galvanometer,  a  pair  of  wires, 
a  flat  pad  for  completing  the  circuit  at  the  negative  pole,  and 
a  rod  or  other  electrode  of  zinc  attached  to  the  positive  pole, 
completes  the  outfit.  The  zinc  must  be  covered  with  three 
or  four  layers  of  gauze,  which  serve  as  a  reservoir  to  hold 
the  zinc  solution,  a  2-percent  solution  of  the  sulphate 
being  suitable.  The  zinc  should  be  freshly  cleaned  or 
amalgamated,  and  the  solution  should  be  made  with  dis- 
tilled water.  It  is  as  well  not  to  touch  the  zinc  electrode 
or  its  covers  with  the  fingers  unnecessarily,  because  every 
touch  imparts  a  trace  of  sodium  chloride  from  the  skin, 
and  tends  to  reduce  the  efficiency  of  the  process  a  little  by 
bringing  in  some  foreign  ions.  The  circuit  is  completed 
through  the  usual  pad  electrode  applied  to  any  convenient 
part  of  the  patient,  the  zinc  electrode  of  suitable  size  is 
held  on  the  rodent  ulcer,  and  the  current  is  slowly  turned 
on  until  a  current  of  5 , 8  or  10  milliamperes  is  reached,  accord- 
ing to  the  size  of  the  electrode  used;  the  seance  continuing 
about  fifteen  minutes. 

RUBBER  GLOVES:   MURPHY'S  SUBSTITUTE 

Operators  (or  assistants)  who  cannot  wear  rubber  gloves 
for  operations  like  hernia  may  employ  the  solution  of  gutta- 
percha  in  benzin.  It  is  prepared  as  follows:  Gutta 
chips  are  cut  in  small  pieces,  washed  in  full-strength 
(4o-percent)  formalin  and  dried  in  sterile  gauze.  Macerate 
in  sterilized  benzin  for  three  days,  and  filter  through 
sterilized  cotton,  twice.  Benzin  is  rendered  sterile  by 
putting  it  in  a  strong,  well-corked  bottle  and  boiling  for 


278  SURGICAL  THERAPEUTICS 

twenty  minutes,  the  water  being  only  warm  when  the  bottle 
is  placed  in  it.  But  as  this  solution  deteriorates,  like  rub- 
ber, it  is  best  to  buy  sterilized  gutta-percha  (on  the  market 
in  sealed  envelopes  graduated  for  4-,  8-  and  i6-ounce  mix- 
tures) and  dissolve  a  little  in  the  benzin  each  time. 

Method  of  Use* — The  hands  are  thoroughly  scrubbed 
and  washed  in  65-percent  alcohol  for  three  minutes.  They 
are  then  dried  with  a  sterile  towel.  The  solution  is  best 
applied  by  dipping  the  hands  into  a  small  basin  containing 
the  solution.  It  should  be  worked  in  around  the  nails  and 
tips  of  the  fingers,  and  should  be  applied  as  high  as  the 
elbows.  Between  operations  the  hands  may  be  washed 
with  soap  and  water,  spirit  of  soap,  alcohol,  bichloride 
solutions,  phenol  or  formalin  solution,  without  interfering 
with  the  rubber  coating.  Brushes,  however,  should  not 
be  used.  After  cleansing  the  hands  and  before  proceeding 
with  another  operation,  the  fingers  should  be  redipped,  as 
the  coating  wears  off,  but  one  application  on  the  hands 
and  forearms  is  sufficient  for  the  entire  day.  The  skin  of 
the  operator  does  not  become  "water  logged"  or  shriveled 
with  the  solution,  as  it  does  with  the  rubber  gloves.  The 
coating  is  best  removed  by  washing  the  hands  in  benzin 
and  drying  rapidly  with  a  towel. 

SAPREMIA 

This  is  an  acute  febrile  condition,  the  result  of  absorp- 
tion of  the  products  of  putrefaction.  The  proper  treat- 
ment is  instant  removal  of  the  cause,  with  physic  and 
antipyretic  agent,  a  dose  of  acetanilid  followed  by  aconitine 
being  very  satisfactory.  The  most  frequent  cause  of 
sapremia,  it  should  be  remembered,  is  retention  of  frag- 
ments of  placenta  or  decomposing  blood-clot;  emptying 
the  uterus  promptly  relieves  the  trouble  if  free  drainage 
through  the  cervix  be  provided  and  the  vagina  be  kept 
clean  by  douching. 


SCARS  279 

SARCOMA 

This  is  an  exceedingly  malignant  tumor  made  up  of 
embryonal  connective  tissue,  the  small-celled  and  those  of 
soft  consistency  being  particularly  malignant.  It  is  likely 
to  appear  much  earlier  in  life  than  carcinoma.  It  is  most 
often  found  in  the  skin,  periosteum,  intermuscular  septa, 
subserous  connective  tissue  and  the  eye.  Whatever  the 
type,  the  earlier  it  is  removed  the  better.  Neighboring 
lymphatic  glands  are  not  implicated  as  in  carcinoma  but 
extension  along  blood-vessels  must  be  looked  for.  When 
not  removable  it  is  to  be  treated  by  x-ray  and  by  injec- 
tion of  Coley's  serum  (mixed  toxins  of  streptococcus  and 
bacillus  prodigiosus)  from  which  excellent  results  are  occa- 
sionally obtainable. 

SCALDS- 

Severe  scalds  should  be  treated  practically  the  same  as 
burns  of  the  second  degree,  exclusion  of  the  air  from  the 
burned  surface  being  of  especial  necessity.  If  the  affected 
surface  be  extensive  the  kidneys  must  be  watched  carefully, 
as  a  great  strain  is  thrown  on  them  and  if  they  fail  in  their 
work  death  will  follow.  Morphine  must  be  given  with 
care.  If  the  urine  is  drawn  after  two  or  three  hours  and 
found  very  highly  colored  a  gram  (15  grains)  of  citrate  of 
potassium  dissolved  in  a  glassful  of  water  must  be  given 
every  six  hours. 

SCARS 

Cicatrices  which  cause  much  deformity  may  sometimes 
be  remedied  in  great  measure  by  excision  and  transplanta- 
tion of  healthy  skin  into  the  gap;  or  even  by  a  Thiersch 
graft.  When  operation  is  not  possible,  or  not  desired, 
treatment  by  electricity  may  be  tried.  In  some  cases  the 
scars  have  softened,  the  discolorations  have  disappeared, 
the  surface  taking  on  more  nearly  the  appearance  of  normal 
skin.  The  application  is  made  with  two  large  electrodes 


280  SURGICAL  THERAPEUTICS 

moistened  with  a  lo-percent  salt  solution.  The  negative 
electrode,  which  is  applied  to  the  sacrum,  has  an  area  of 
30  square  inches.  This  is  connected  with  the  positive  pole 
of  the  induction  coil,  and  this  electrode  has  a  surface  of 
about  1 6  square  inches.  The  apparatus  should  have  a 
commutator  that  will  enable  the  operator  to  use  either  the 
galvanic  or  faradic  current  alone  or  the  two  combined. 
The  strength  of  the  constant  current  employed  to  be  only 
from  3  to  4  milliamperes.  The  induction  current  should 
be  sufficiently  intense  to  provoke  appreciable  contraction 
of  the  muscles.  Each  treatment  should  last  from  fifteen 
to  twenty  minutes. 

Ugly  Scars* — For  a  period  varying  from  a  few  months 
to  a  year  or  two,  scars  remain  red  or  purple,  sometimes 
causing  great  disfigurement.  Nothing  can  be  done  except 
to  wait;  after  a  long  time  they  become  pale  and  finally  white. 
If  in  such  location  that  they  can  be  removed  and  unin- 
jured skin  secured  to  cover  the  denuded  area  it  is  proper  to 
excise  them  under  strictest  antisepsis,  suppuration  causing 
as  much  cicatricial  tissue  as  was  cut  out,  and  sometimes 
more. 

SCOLIOSIS 

Every 'case  of  curvature  of  the  spine  should  be  treated, 
howsoever  slight  it  may  be,  not  on  account  of  present  de- 
formity but  because  it  may  be  followed  by  tuberculosis 
and  is  an  indication  of  a  morbid  condition  of  the  general 
health.  According  to  Codicilla,  a  careful  research  has 
demonstrated  that  scoliosis  is  a  form  of  contracture,  and  for 
such  conditions  the  rational  treatment  is  active  and  passive 
movements  in  the  deformed  portions  of  the  spine  alone, 
the  normal  portions  remaining  fixed.  The  best  results  were 
obtained  by  the  author  with  the  apparatus  of  Schulten. 
The  apparatus  of  Zander  is  easier  of  application  and  also 
gives  excellent  results. 


SEMINAL  VESICLES:  TUBERCULOSIS  OF          281 

SEMINAL  EMISSIONS 

These  usually  depend  upon  an  irritable  deep  urethra 
or  excitable  sexual  center  in  the  spinal  cord.  A  Xo.  16 
(American  scale)  catheter  introduced  every  third  day  for 
two  weeks,  and  allowed  to  remain  two  minutes  the  first 
time  and  one  minute  longer  every  time  until  ten  minutes  are 
reached,  will  diminish  this ;  after  which  a  few  injections  of 
solution  of  nitrate  of  silver  (10  grains  to  the  ounce)  through 
a  Guion's  or  Ultzmann's  syringe — ten  drops  behind  the 
''cut-off  muscle"  twice  a  week — will  permanently  relieve  the 
hyperesthesia.  Hyoscine  hydrobromide  (i-ioo  grain)  at 
bedtime,  alone  or  with  20  grains  of  potassium  bromide, 
relieves  the  spinal  irritation.  One  emission  a  week  demands 
no  treatment  whatsoever. 

SEMINAL  VESICLES:   TUBERCULOSIS  OF 

When  it  is  definitely  determined  that  tuberculosis  of 
the  seminal  vesicles  is  present  (either  alone  or  associated  with 
tuberculo.-is  of  the  testicle  or  epididymis)  removal  is  the 
only  rational  treatment  if  the  patient  desires  to  live  any  great 
length  of  time.  It  is  practically  always  associated  with 
disease  of  the  testicles  and  vas  deferens,  although  its 
severity  bears  no  relation  to  the  extent  of  these  lesions  and 
both  vesicles  may  be  involved  in  one-sided  orchitis.  The 
symptoms  are  not  striking  as  a  rule.  There  is  usually 
vesical  tenesmus,  and  there  may  be  rectal  tenesmus  and 
pain  at  stool.  Examination  reveals  an  obliteration  of  the 
groove  normally  felt  between  these  organs  and  the  prostate 
gland.  Occasionally  there  is  a  fistula  leading  to  the  per- 
ineum. The  prostate  is  enlarged  in  about  one-third  of  the 
cases.  Treatment  may  not  be  necessary  in  early  cases, 
the  lesion  sometimes  healing  spontaneously  after  removal 
of  the  diseased  testicle.  If,  however,  there  is  a  fistula  or 
extreme  difficulty  at  stool,  or  if  the  organ  is  as  large  as  the 
last  joint  of  the  surgeon's  thumb,  it  should  be  removed, 


282  SURGICAL  THERAPEUTICS 

unless  there  is  tubercular  disease  of  the  bladder  or  kidney, 
which  may  be  looked  upon  as  contraindications.  The 
operation  of  choice  is  perineal  excision  by  a  Y-shaped 
incision,  the  shaft  of  the  Y  pointing  forward  in  the  middle 
line  and  the  arms  embracing  the  front  of  the  anus.  Drain- 
age and  healing  by  granulation  are  always  to  be  provided 
for. 

SEPTICO-PYEMIA 

This  is  a  name  applied  to  a  condition  in  which  septi- 
cemia  is  followed  or  accompanied  by  pyemia.  Leube  uses 
the  words  "spontaneous  septicopyemia "  for  a  form  of 
pyemia  which  appears  without  obvious  cause,  or  at  least 
following  a  skin-wound  or  bruise  so  trifling  as  to  scarcely 
be  remembered.  It  is  characterized  by  pain  and  tender- 
ness in  the  muscles  and  joints  with  high  fever,  irregular 
chills,  fetid  breath  and  septic  diarrhea.  There  are  also 
present  from  time  to  time  ecchymoses  of  the  conjunctiva, 
vesicles  of  the  skin  which  contain  blood,  enlargement  of 
the  spleen,  and  albuminuria.  Death  by  coma  usually 
ends  the  scene.  A  supportive  and  eliminative  treatment, 
with  the  injection  of  Marmorek's  serum,  if  the  presence  of 
streptococci  can  be  demonstrated,  constitute  all  the  ther- 
apeutic measures  that  are  beneficial. 

Experiments  made  in  Germany  on  animals  go  to  prove 
that  the  intravenous  injection  of  antiseptics  are  of  no  value 
in  blood  poisoning,  but  good  results  are  recorded  from  hot 
baths,  which  promote  elimination  by  the  skin  and  lymphatic 
system.  The  internal  administration  of  calcium  sulphide 
is  worthy  of  trial. 

Headache  of  Sepsis. — For  the  relief  of  headache 
acetanilid  may  be  given — guardedly  if  the  heart  be  weak. 
A  dose  of  ten  grains  may  be  ordered;  it  may  be  repeated 
in  one  hour  if  indicated,  but  no  more  should  be  permitted 
until  twenty-four  hours  have  elapsed.  A  tablet  called 


SEXUAL  DISORDERS  283 

"acetanilid  and  codeine  compound"  will  be  found  prefer- 
able in  some  cases.     It  consists  of 

Acetanilid grs.  3  1-2 

Sodium  bromide gr.       i-io 

Sodium  bicarbonate gr.       9-10 

Codeine  sulphate gr.       1-4 

The  dose  is  one  or  two  when  needed  for  pain;  to  be 
repeated  once  only  if  the  first  dose  does  not  produce  comfort. 

SEQUESTRUM:    REMOVAL  OF 

Whenever,  in  the  healing  of  a  fracture,  a  detached 
fragment  of  the  bone  does  not  grow  into  the  callus  and  form 
once  more  a  part  of  the  living  bone,  it  becomes  necrotic  and 
a  source  of  irritation.  The  only  treatment  is  by  removal. 
The  same  is  true  of  a  sequestrum  formed  by  tuberculous 
disease,  but  in  this  kind  of  trouble  the  cavity  must  be  cureted 
and  packed  with  iodoform  and  iodoform  gauze,  and  allowed 
to  heal  by  granulation  from  the  bottom. 

SEXUAL  DISORDERS 

Sexual  Debility:  Senecin  for — If  there  is  any  drug 
which  may  properly  be  called  a  "sexual  tonic"  it  is  senecin: 
the  active  agent  of  senecio  aureus  or  "squawroot. "  The 
dose  is  one  to  two  milligrams  (gr.  1-6  to  gr.  1-2)  three 
or  four  times  a  day.  It  is  most  highly  recommended  for 
women  who  complain  chiefly  of  a  sensation  of  weight  and 
dragging  in  the  pelvis,  yet  who  have  neither  prolapse  nor 
laceration  of  the  pelvic  floor  as  a  cause. 

Sexual  Depressant:  A  Good — For  the  control  of 
nymphomania,  as  well  as  depressant  of  eroticism  or  ere- 
thism in  morbidly  excitable  patients  who  are  compelled 
by  circumstances  to  observe  enforced  continency,  the  follow- 
ing combination  may  be  prescribed: 

Calcium  sulphide  o.oi 

Salicin o.oi 

Camphor  monobromate    o.oi 


284  SURGICAL  THERAPEUTICS 

These  may  be  obtained  in  granules  of  one-sixth  of  a* 
grain  each,  or  may  be  dispensed  in  capsules  with  some 
convenient  vehicle.  If  in  granules,  the  dose  is  one  or  two 
every  four  or  six  hours.  Four  may  be  taken  a  little  before 
bedtime  so  that  erotic  dreams  and  sensations  may  be 
avoided  during  the  hours  of  sleep.  The  camphor 
monobromate  may  be  increased  to  4  or  5  grains  if 
necessary. 

Sexual  Irritation:  Symptoms  of — The  intimate  con- 
nection which  exists  between  the  sexual  sphere  and  the 
skin  is  well  shown  in  certain  pathological  conditions  of  the 
latter,  dependent  upon  the  irritation  of  the  former.  The 
appearance  of  many  pimples  upon  the  face  is  a  common 
accompaniment  of  the  menstrual  period  with  perhaps  a 
majority  of  women;  and  the  occurrence  of  persistent  acne 
in  girls  at  adolescence,  when  there  is  an  unusual  degree 
of  sexual  disturbance  (masturbatory  or  otherwise)  is  well 
known.  It  dies  out,  usually,  with  the  completion  of  adoles- 
cence or  by  the  complete  sexual  gratification  of  married 
life;  but  it  is  apt  to  appear  at  the  time  of  the  menopause, 
since  this  is  a  period  of  sexual  excitement  with  many 
women. 

Sexual  Neurasthenia. — As  an  aphrodisiac  as  well  as 
general  tonic  in  sexual  neurasthenia  "the  three  arsenates" 
with  nuclein  will  often  give  satisfactory  results.  A  tablet 
consisting  of 

Strychnine  arsenate 0.0005  (gr.  1-134)     . 

Quinine  arsenate o.ooi    (gr.  i-  67) 

Iron  arsenate o.ooi    (gr.  i-  67) 

Nuclein   solution  0.25  (drops       4) 

may  be  ordered,  of  which  one  is  to  be  taken  every  two 
hours,  or  three  after  each  meal  and  at  bedtime.  In  the  debility 
of  advancing  age  this  has  given  most  excellent  results. 
Nuclein  is  declared  to  be  the  most  powerful  known  stimu- 
lant to  the  sexual  organs. 


SHOCK  285 

SHOCK 

In  that  form  of  shock  due  to  severe  impression  on 
the  central  nervous  system,  as  when  a  large  bone  is  sud- 
denly shattered  or  a  cavity  penetrated  or  an  important 
viscus  is  wounded  or  a  limb  injured  by  a  pistol  or  rifle  ball, 
the  effect  is  often  profound — the  most  prominent  symptom 
being  the  general  distress  of  mind  and  alarm  which  the 
patient  shows  upon  his  face  and  which  comes  on  almost 
instantaneously  upon  the  infliction  of  the  injury.  The  patient 
trembles  and  totters,  is  pale,  complains  of  being  faint, 
perhaps  vomits,  and  sinks  to  the  ground;  his  features  express 
extreme  anxiety  and  distress.  This  emotion  is  in  great 
measure  instinctive  and  seems  to  be  a  sympathy  of  the 
whole  frame  with  the  part  subjected  to  serious  injury,  ex- 
pressed through  the  nervous  system.  The  first  indication 
is  to  check  hemorrhage;  the  second  to  stimulate  the  heart. 
Whisky  is  not  bad.  A  hypodermic  injection  of  glonoin 
is  next  advisable,  followed  by  atropine  to  maintain  its 
influence;  and  later  one  of  strychnine,  with  a  little  mor- 
phine if  pain  is  a  prominent  symptom. 

Post-Operative  Shock. — After  a  serious  operation 
there  is  of  necessity  a  period  characterized  by  weak  and 
rapid  heart-action,  the  result  of  hemorrhage  and  pain ;  but 
this  should  be  transient.  Martin  says  if  in  an  adult  the 
pulse  remains  above  144  for  more  than  six  hours  the  condi- 
tion is  distinctly  dangerous.  After  twelve  hours  the  prog- 
nosis is  bad,  and  after  more  than  twenty-four  hours  nearly 
but  not  quite  hopeless.  Whatever  be  the  cause  of  this  condi- 
tion, its  cure  is  dependent  upon  active  stimulation  supple- 
mented by  elimination.  Therefore  in  addition  to  external 
heat  dilute  hot  rectal  injections  are  highly  important.  Of 
these  coffee  takes  first  rank,  one  pint  of  this  at  a  tem- 
perature of  from  112  to  116  degrees  being  thrown  into 
the  rectum.  The  stomach  under  these  circumstances  is 


285  SURGICAL  THERAPEUTICS 

non-absorbent  and  extremely  prone  to  acute  dilation. 
Therefore,  unless  dilated,  it  should  be  left  alone.  In  the 
cases  associated  with  acute  dilatation,  or  followed  by  long- 
continued  vomiting,  the  stomach  should  be  emptied  by  tube 
and  irrigated  with  hot,  salt  solution,  but  there  is  danger  of 
reflex  cardiac  inhibition. 

Shock  "With  Abdominal  Pain. — Very  often  in  abdo- 
minal disease  and  acute  trauma  the  patient's  mind  becomes 
dulled:  apathy — and  later  unconsciousness — appears;  urine 
excretion  is  diminished  or  absent,  the  pulse  and  respira- 
tion become  impreceptible,  temperature  subnormal,  pupils 
dilated,  slowly  responsive  or  fixed,  and  death  occurs 
speedily,  in  the  severe  types  of  disease  or  injury.  Vomit- 
ing is  frequently  prominent,  but  comes  from  acute  sepsis, 
not  peritonitis.  A  death  of  this  kind  very  soon  after  an 
injury  or  rupture  of  an  abscess  may  usually  be  said  to 
be  due  to  shock;  but  if  death  be  delayed  more  than  a 
few  hours  it  is  from  acute  sepsis.  "Deferred "  or  "delayed" 
shock  is  sepsis,  pure  and  simple.  But  there  is  a  true 
shock  associated  with  acute  pain:  Severe  traumatism 
(especially  if  productive  of  sudden,  complete  rupture  of 
liver  or  spleen  or  perforation  of  bowel,  uterus  or  bladder) ; 
violent  hemorrhage;  acute  pancreatitis;  sudden  complete 
blocking  of  the  ureter,  the  biliary  passages,  or  even  the 
pancreatic  duct;  mesenteric  embolism;  sudden  strangula- 
tion of  the  gut  or  even  omentum  by  constriction  of  a  hernia 
or  twist;  torsion  of  the  pedicle  of  an  ovarian  or  uterine 
tumor — all  these  are  always  more  intensely  shocking  than 
the  same  lesions  when  slowly  produced,  and  are  always 
accompanied  by  much  suffering.  From  this  kind  of  shock 
the  temperature  slowly  rises,  often  going  to  100;  but  the 
chief  guide  is  the  pulse.  A  progressive,  even  slight,  hurry- 
ing and  weakening  of  the  pulse,  with  or  without  persistent 
lowering  of  body- temperature,  is  indicative  either  of  per- 
sistence of  the  exciting  cause,  the  superaddition  of  more 


SKULL:  WOUNDS  OF  287 

or  less  sepsis  or  of  gangrene;  and,  especially  if  accom- 
panied by  cessation  of  pain,  may  be  regarded  as  a  pretty 
constant  indication  for  immediate  operation. 

SILICATE  OF  SODIUM  SPLINTS 

This  formula,  for  the  manufacture  of  a  firm,  durable 
splint — very  valuable  in  the  fixation  of  certain  fractures 
after  the  swelling  has  subsided — has  been  sold  to  many 
physicians  for  ten  dollar; — sometimes  more: 

Powdered  starch ounce  i 

Isinglass   or  gelatin i ounce  i 

Solution  of  sodium  silicate quart  i 

Powdered  boric  acid ounce      1-2 

Mix  the  starch  with  the  solution  of  sodium  silicate 
by  shaking  through  a  pepper-box  and  stirring  constantly 
till  mixed.  Reduce  the  gelatin  to  the  consistency  of 
mucilage  with  boiling  water  and  mix  well  with  the  first 
two.  (Better  swell  with  cold  water  first.)  Then  put 
in  a  jug  of  double  the  capacity  and  ferment  at  room  or 
sun  temperature  for  three  or  four  days.  Then  add  the 
boric  acid,  mix  well,  and  it  is  ready  for  use.  If  too  thick 
after  standing,  thin  it  with  boiling  water.  Keep  the 
jug  well  corked. 

Apply  a  silk  stocking  or  roller  bandage,  then  a  coat 
of  the  preparation  with  a  brush,  and  repeat  till  three  or 
four  layers  are  applied  or  until  the  splint  is  thick  enough. 
It  may  be  cut  after  hardening  and  eyelets  and  laces  put  in. 

SKULL:    WOUNDS   OF 

Every  suspicious  wound  of  the  scalp  should  be  thor- 
oughly explored  to  see  that  there  is  no  fracture  beneath; 
in  case  of  doubt  the  wound  to  be  enlarged  for  perfect 
inspection.  The  following  rules  laid  down  by  Adams 
are  to  be  carefully  observed: 

Gutter  fractures   should  be    invariably  operated  upon 
as  early  as  possible  to  get  rid  of  bone  fragments,  clot  and 


288  SURGICAL  THERAPEUTICS 

debris,  and  to  provide  outlet  for  the  products  of  infec- 
tion which  is  common  to  these  cases.  Without  early 
operation  these  wounds  suppurate,  and  the  operation 
is  too  late.  (Von  Manteuffel.) 

In  transverse  perforating  wounds  cleanse  orifices  and 
await  symptoms. 

In  superficial  penetrating  wounds  with  lodgment, 
exploration  with  removal  of  bone  fragments  and  bullet 
should  be  made  if  practicable. 

In  transverse  penetrating  wounds  cleanse  the  orifice 
of  entrance,  await  symptoms,  and  practise  radiography. 

Cases  of  compression  by  blood  extravasation  with 
localizing  symptoms  are  rarely  seen.  When  extravasa- 
tion can  be  localized  and  is  accessible,  it  should  be  treated 
on  general  surgical  principles. 

In  some  cases  of  penetration  there  may  be  fracture 
of  the  skull  opposite  the  point  of  entrance,  without  exit 
opening. 

Such  a  condition  requires  exposure  and  removal  of 
bone  fragments;  the  bullet  in  such  cases  is  rarely  found 
near  the  second  fracture,  generally  having  been  diverted 
to  some  other  region  by  ricochet  on  the  skull- wall. 

The  question  of  removal  of  a  bullet  lodged  in  the 
cranium  is  one  of  special  interest,  inasmuch  as  a  wide- 
spread belief  prevails  that  a  lodged  bullet  is  per  se  a  most 
dangerous  thing.  The  danger  lies  in  the  damage  done 
to  the  brain  by  the  passage  of  the  bullet  through  its  sub- 
stance, and,  unless  symptoms  arise  which  can  be  traced' 
to  persistent  irritation  by  the  presence  of  the  bullet,  or 
radiography  demonstrates  that  the  bullet  is  in  such  a 
position  as  sooner  or  later  to  produce  irritation,  no  attempt 
should  be  made  to  remove  a  deeply  seated  bullet  from 
the  cranial  cavity.  Whenever  we  are  confronted  by  the 
question  of  the  removal  of  a  deeply  lodged  bullet,  it  should 
be  definitely  ascertained  that  the  symptoms  present  are 


SOAP  SUPPOSITORIES  289^ 

due  to  irritation  from  the  presence  of  the  bullet  itself, 
and  not  to  its  having  inflicted  damage  on  certain  regions 
of  the  brain  on  its  way  to  its  present  location,  for  the 
removal  of  the  bullet  could  in  no  way  affect  the  injured 
cerebral  tissue. 

SNAKE-BITES 

With  any  snake-bite  the  wound  should  be  filled  with 
potassium  permanganate,  well  rubbed  in;  and  a  few 
drops  of  25-percent  solution  should  be  injected  around 
the  site  of  the  injury  If  seen  early,  a  tourniquet  should 
be  applied  a  little  above  the  wound,"  gradually  loosened, 
a  little  each  hour.  The  Western  treatment — as  much 
whisky  as  necessary  to  produce  a  "dead  drunk" — is 
efficacious  chiefly  because  it  does  away  with  the  deadly 
fear.  Two  tablets  of  hyoscine-morphine-cactin  (H-M-C, 
Abbott),  an  hour  apart  hypodermically,  will  do  almost 
as  well,  though  the  profuse  perspiration  induced  by  the 
whisky  probably  helps .  to  quickly  eliminate  the  poison. 
Pilocarpine  hypodermically  is  also  of  benefit  for  this 
same  reason.  A  good  saline  cathartic  is  also  excellent 
given  as  soon  as  possible.  When  the  heart  flags  (from  the 
acute  sepsis)  strychnine,  digit alin  and  sparteine  may 
be  administered,  hypodermically.  Hypodermoclysis  is 
of  value,  also,  to  stimulate  the  flagging  heart  and  help 
rapid  elimination.  Incision  and  sucking  of  the  wound 
at  time  of  bite  often  extracts  much  of  the  poison. 

SOAP  SUPPOSITORIES 

When  glycerin  suppositories  are  not  obtainable,  a 
cheap  and  efficient  substitute  is  soap.  A  piece  about 
the  size  of  a  man's  thumb  is  made  smooth,  is  wetted  and 
pushed  as  far  up  the  rectum  as  a  finger  will  carry  it. 
Loose,  easy  bowel-movement  soon  results.  It  is  par- 
ticularly applicable  to  young  children  who  fight  at  every 
attempt  to  give  an  enema. 


290  SURGICAL  THERAPEUTICS 

SPERMATOCELE 

This  form  of  "retention  tumor"  is  quite  rare.  If 
the  obstruction  to  the  outflow  of  semen  be  complete  the 
tumor  may  eventually  attain  considerable  size  as  pre- 
senting clinically.  It  contains  non-albuminous  fluid  with 
great  numbers  of  spermatozoa.  Their  origin  is  not  always 
the  same,  but  in  the  main  is  that  of  retention-cysts  formed 
in  various  ways,  either  externally  or  internally,  by  obstruc- 
tion of  the  seminal  tubules.  Their  diagnosis  before 
tapping  is  not  easy,  but  may  be  helped  by  ascertaining 
the  position  of  the  testis.  Treatment  either  by  injection 
of  irritating  solutions  or  by  operation  is  exceedingly  simple 
and  satisfactory 

SPINA    BIFIDA 

When  parents  will  not  consent  to  operative  measures 
or  when  the  case  is  presumed  not  to  be  favorable  for  sur- 
gical treatment  Morton's  method  may  be  adopted:  injec- 
tion into  the  sac  of  one  dram  of  a  preparation  of  10  grains 
of  iodine  and  30  grains  of  potassium  iodide  in  one  ounce 
of  sterilized  glycerin.  About  one  dram  of  cerebrospinal 
fluid  is  permitted  to  run  through  the  needle  before  the 
injection  is  made.  The  point  of  entrance  is  covered  with 
bichloride  gauze  and  a  bandage  not  too  tightly  applied. 

SPINE:    DEFORMITIES  OF 

The  present  status  of  these  troubles  is  well  summarized 
by  Cokenower,  thus:  (i)  The  statistics  and  histories 
of  all  cases  of  deformities  of  the  spine,  even  in  children, 
shortens  longevity,  and  especially  so  with  extreme  scoliosn 
when  the  average  age  does  not  exceed  30.  (2)  All 
deformities  of  the  spine  can  be  relieved  if  treatment  i.; 
begun  early  or  so  soon  as  any  deformity  exists,  and  those 
without  bone  deviations  are  simple  and  amenable  to 
successful  correction,  and  those  with  osseous  change, 


SPLEEN:  ABSCESS  OF  291 

even  in  children,  can  be  improved,  but  not  so  in  ado- 
lescence and  adults.  (3)  The  law  of  growth  and  develop- 
ment of  osseous  as  well  as  soft  tissue  is  fully  demonstrated 
in  the  abnormalities,  distortions,  deformities  and  actual 
and  permanent  normal  functional  disturbances;  when 
the  equilibrium  of  the  normal  axis  of  the  body  has  been 
destroyed,  no  matter  whether  it  be  (he  result  of  torticollis, 
knock-knee,  bow-legs,  club-foot,  short-leg  or  any  other 
cause,  the  results  are  the  same  according  to  severity. 
(4)  The  medicinal  and  mechanical  treatment  should  be 
augmented  with  hygiene,  gymnastics  and  all  other  prop- 
erly guarded  means  that  will  develop  the  body,  give  tone 
and  power  to  the  muscles,  increase  vital  functions  and 
materially  improve  the  general  health. 

SPLANCHNOPTOSIS 

This  is  a  name  given  to  general  prolapse  of  the  abdo- 
minal organs;  including  gastroptosis,  enteioptosis  and 
prolapsus  uteri,  and  sometimes  hepatoptosis  and  spleno- 
ptosis.  With  these  are  associated  certain  nervous  symp- 
toms generally  called  "Glenard's  disease."  Relief  of 
the  ptoses  by  either  mechanical  support  or  by  surgical 
intervention  rarely,  therefore,  cure  the  patients  unless 
followed  by  judicious  internal  medication  continued  over 
a  long  period  of  time. 

SPLEEN:    ABSCESS  OF 

A  few  cases  of  abscess  of  the  spleen  have  been  cured 
by  making  a  large  incision  (sometimes  with  removal  of 
a  part  of  eleventh  and  twelfth  ribs)  and  opening  the  abscess 
after  carefully  surrounding  with  gauze.  When  thoroughly 
evacuated  the  abscess-cavity  is  to  be  tightly  tamponed 
with  iodoform  gauze  and  the  splenic  peritoneum  sutured 
to  the  parietal  around  the  entire  circumference,  the  parietal 
peritoneum  being  dissected  off  for  a  considerable  distance 


292  SURGICAL  THERAPEUTICS 

if  necessary,  in  order  to  render  it  sufficiently  loose  to  per- 
mit sewing  without  undue  strain  upon  it.  Then  gauze  is 
to  be  carefully  packed  in  between  this  line  of  sutures  and 
the  gauze-pack,  to  prevent,  if  possible,  leakage  of  pus 
for  a  few  hours,  until  protective  adhesions  can  form. 
When  the  patient's  condition  is  such  that  prolonged  opera- 
tion is  impossible  it  may  be  necessary  to  rely  upon  careful 
packing  alone,  the  abdomen  being  bandaged  tightly  for  a 
few  hours  and  patient  kept  lying  upon  the  left  side,  to  force 
spleen  against  abdominal  wall  and  thus  favor  promotion 
of  the  adhesions  upon  which  life  depends.  Splenectomy 
is  rarely  possible  on  account  of  the  deplorable  condition 
of  the  patient  by  the  time  a  diagnosis  is  made.  Sub- 
sequent treatment  is  merely  free  drainage  and  tonics  inter- 
nally. 

SPONDYLITIS 

This  name  is  frequently  used  as  a  synonym  of  Pott's 
disease,  inflammation  of  one  or  more  vertebrae  of  tuber- 
culous origin.  It  is  treated  by  immobilization  and  gen- 
eral antituberculous  medication.  Spondylitis  deformans 
is  an  affection  generally  described  as  an  "inflammation" 
of  the  vertebras  of  gouty  or  rheumatic  origin,  terminating 
in  ankylosis  and  deformity.  There  are  no  curative  meas- 
ures, though  rarely  an  improvement  follows  systematic 
muscular  training  with  some  mechanical  assistance. 

SPRAINS 

This  is  a  name  applied  to  an  injury  to  a  joint,  the 
pathology  being  a  strain  of  muscle,  tendon  or  ligament, 
frequently  with  more  or  less  tearing  of  the  implicated 
structures  and  with  an  outpouring  of-  blood  from  the 
rupture  of  small  vessels.  Very  often  that  which  is  gen- 
erally called  "sprain"  includes  epiphyseal  separation 
or  fracture  of  bone  as  well  as  injury  to  the  soft  parts. 


STATUS  LYMPHATICUS  293 

A  special  form  is  known  as  "riders'  sprain"  an  injury 
to  the  adductor  longus  muscle  of  the  thigh,  from  a  sud- 
den effort  to  retain  one's  seat  when  the  horse  springs 
sidewise.  The  soreness  sometimes  persists  for  many 
days  in  spite  of  active  massage  and  application  of  stimu- 
lating and  pain-relieving  liniments. 

Ichthyol  for  Sprains. — To  remove  the  swelling 
which  follows  a  severe  sprain,  especially  of  the  ankle, 
when  the  ambulatory  instead  of  fixation-treatment  is  to 
be  adopted,  ichthyol  may  be  ordered  for  frequent  and 
deep  massage.  On  account  of  its  nasty  smell  phenol 
may  be  added,  or  oil  of  citronella.  It  should  be  com- 
bined with  lanolin  to  get  best  results: 

Ichthyol 8.0  (drs.    2) 

Lanolin 32.0  (oz.      i) 

Oil  of  citronella 2.0  (grs.  30) 

Mix.  Directions:  Apply  by  deep  massage  three  or 
four  times  a  day. 

STATUS  LYMPHATICUS 

This  peculiar  condition,  associated  with  an  enlarged 
thymus  gland  and  hyperplasia  of  the  lymphatic  glands, 
is  presumed  to  be  the  cause  of  death  in  some  of  the 
fatalities  reported  from  ether  (and  chloroform)  anesthesia. 
The  number  of  recorded  cases  in  which  status  lumphaticus 
has  been  found  in  adults  is  increasing.  Many  of  the  sud- 
den deaths  which  follow  chloroform  narcosis  are  reported 
from  Europe,  and  are  found  to  be  due  to  this  cause.  The 
recognition  of  status  lymphaticus  by  American  surgeons 
by  whom  ether  is  more  often  used  than  chloroform  has 
shown  that  death  in  such  cases  may  follow  ether  narcosis. 
It  is  possible  that  the  anesthetic  may  have  nothing  to  do 
with  death  in  these  cases.  The  iccognition  of  status  lym- 
phaticus is  very  difficult  during  life.  A  slight  increase 
of  dulness  to  the  lefc  of  the  iter  um  or  enlarged  lymph 


294  SURGICAL  THERAPEUTICS 

nodes,  together  with  a  pale  skin  and  well  developed  super- 
ficial fat,  raises  a  suspicion  of  such  a  stale,  but  these  signs 
can  hardly  be  relied  upon  to  identify  the  condition. 

In  the  treatment  of  failure  of  respiration  the  condition 
in  artificial  respiration  is  of  little  use,  and  the  heart  stops 
so  quickly  that  drugs  have  little  time  to  reach  the  cardiac 
and  respiratory  centers  even  if  given  hypodermically 
after  the  collapse  is  first  noticed.  It  is  possible  to  antici- 
pate shock  by  giving  digitalis  before  the  operation  and 
morphine  and  hyoscine  hypodermically  just  before  the 
anesthetic  is  started.  Intravenous  injection  of  adrenalin 
in  normal  saline  solution,  i  in  50,000,  has  been  shown  by 
Crile  to  stimulate  the  heart  and  rapidly  increases  blood- 
pressure,  and  is  unquestionably  a  useful  procedure  in 
these  cases. 

STERILIZATION  IN  SURGERY 

Sterilization  of  Instruments* — All  instruments  to 
be  used  in  aseptic  operations  must  be  boiled  for  twenty 
minutes  just  before  using.  This  applies  to  knives  and 
scissors  as  well  as  other  utensils,  but  in  order  to  be  certain 
that  they  are  not  dulled  by  this  process  about  one  teaspoon- 
ful  of  washing  soda — sodium  carbonate,  not  the  bicarbonate 
used  in  cooking,  which  is  useless  for  this  purpose — must 
be  added  to  each  quart  of  water.  In  hospitals  the  instru- 
ments as  well  as  gauze  may  be  sterilized  by  steam,  but 
it  requires  a  long  time,  whereas  by  boiling,  the  things  are 
ready  by  the  time  the  hands  are  cleansed.  The  water 
may  be  poured  off  and  the  pan  allowed  to  stand  for  a  few 
minutes  to  cool  in  a  place  where  there  is  no  dust,  or  cov- 
ered by  a  towel  out  of  boiling  water.  When  everything 
else  is  ready  the  instruments  are  to  be  taken  from  the  boiler 
and  laid  upon  towels  just  taken  from  the  sterilizer  or  boiler 
(and  not  handled  by  anyone)  or,  better,  placed  in  three  or 
four  pans  properly  sterilized.  They  must  be  so  placed 


STERILIZATION  IN  SURGERY  295 

that  wind  does  not  blow  over  them  and  that  no  one  save 
operator  or  assistant  shall  touch  them. 

Sterilization  of  Pans. — In  most  hospitals  and  in 
practically  every  operation  in  a  private  house  too  little 
attention  is  paid  to  the  sterilization  of  pans.  In  hospitals 
they  may  be  rendered  surgically  clean  by  placing  them 
in  the  sterilizer  for  an  hour  in  steam  of  high  pressure; 
if  not,  they  must  be  cleaned  as  in  a  private  house,  viz., 
(i)  by  thorough  scrubbing  outside  and  in  with  soap  and 
water,  (2)  drying  with  a  clean  towel  and  (3)  pouring  a 
little  alcohol  over  each  and  setting  it  afire.  This,  however, 
sterilizes  only  the  interior  of  the  pan  or  basin.  A  better 
way  if  there  be  time  enough  is  to  put  a  wash-boiler  on 
the  kitchen  stove,  fully  two-thirds  filled  with  clean  well- 
water  or  cistern-water  and  boil  all  the  pans  and  trays  for 
twenty  minutes.  In  the  pot  should  be  placed  (a)  two  pans 
for  instruments,  (b)  one  smaller  pan  or  platter  for  sutures 
and  ligatures,  (c)  one  small  bowl  for  alcohol,  (d)  one 
large  earthen  bowl  for  sublimate  solution,  (e)  one  large 
bowl  for  boiled  water,  (f)  one  long-handled  dipper.  After 
these  have  boiled  the  required  time  they  are  to  be 
taken  out  by  means  of  a  sterilized  8-inch  clamp  or  for- 
ceps, and  no  one  beside  the  surgeon  or  assistant  permitted 
to  touch  them.  A  sterilized  towel  should  be  hung  over 
one  end  of  the  boiler  for  the  long-handled  dipper  to  lean 
against  because  the  upper  part  of  the  boiler  will  not  be 
surgically  clean  and  the  water  wilt  be  contaminated  by 
the  dipper's  falling  into  it  if  this  precaution  is  not  taken. 
With  the  same  pains  or  in  the  same  pot  may  be  boiled 
the  towels  or  torn-up  sheets  or  old  cloths  which  are  to  be 
used  around  the  field  of  operation.  And  the  water  may 
be  used  for  making  the  solutions  and  for  washing  purposes: 
hands,  skin  of  patient,  etc.  In  private  houses  extreme 
vigilance  is  essential  to  prevent  too  willing  neighbors  from 
sticking  their  dirty  fingers  into  the  water,  dipping  hot 


296  SURGICAL  THERAPEUTICS 

water  out  of  the  surgeon's  boiler,  etc.     It  is  therefore  best 
to  have  the  room  emptied  while  completing  operations. 

STOMACH 

Cancer  of  Stomach. — There  can  be  no  doubt  but  that 
cancer  of  the  stomach  is  curable  by  early  operation;  the 
trouble  is  to  determine  its  existence  very  early,  and  to  con- 
vince the  patient  of  the  seriousness  of  his  condition;  and 
often  life  may  be  prolonged  and  rendered  far  more  com- 
fortable very  late  in  the  disease.  For  this  reason  an 
exploratory  operation  should  be  done,  even  in  cases  where 
the  disease  is  advanced  and  a  tumor  is  perceptible.  When 
the  disease  is  too  extensive  for  any  radical  operation  to 
be  done,  the  palliative  operation  of  gastroenterostomy  is 
indicated.  It  can  be  done  with  very  small  risk  and  may 
considerably  prolong  life.  Besides,  some  cases,  thought 
to  be  cancer,  too  extensive  for  removal,  have  cleared  up 
after  a  gastroenterostomy,  the  patients  getting  quite  well. 
In  cases  of  disease  of  the  cardiac  end  of  the  stomach  too 
extensive  for  removal,  the  operation  of  gastrostomy  may 
considerably  prolong  life  and  prove  of  great  comfort  to 
the  patient  by  preventing  death  from  starvation.  Even 
when  the  disease  is  too  'extensive  for  either  removal  or  a 
gastroenterostomy,  the  operation  of  jejunostomy  may  prove 
of  service  to  the  patient.  When  a  radical  operation  can 
be  performed,  the  thorough  removal  of  the  disease  may 
bring  about  as  much  relief  to  the  patient  as  does  the  opera- 
tion for  the  removal  of  cancer  of  the  breast,  uterus,  and 
other  organs  of  the  body.  Following  any  of  these  opera- 
tions food  is  to  be  selected  of  such  character  that  all  of  the 
digestion  shall  be  intestinal;  otherwise  fatal  diarrhea  will 
be  set  up. 

After-Treatment  of  Stomach  Operations. — Upon 
being  returned  to  bed  the  patient  should  be  placed  with 
head  and  shoulders  considerably  elevated,  unless  severe 


STREPTOCOCCIC  FEVER:  OPERATION  IN        297 

shock  demands  temporary  lowering  of  the  head,  because 
such  position  best  relieves  tension  on  the  sutures  and 
facilitates  passage  of  gastric  mucus  through  the  pylorus 
or  anastomosis  hole.  Later  the  patient  may  be  turned 
upon  the  right  side  for  a  rest,  once  or  twice  daily. 

Should  vomiting  persist  after  the  second  day  the  stomach 
must  be  carefully  washed  out,  a  little  sodium  bicarbonate 
being  added  to  the  water.  This  lavage  must  be  done  with 
extreme  gentleness,  with  the  patient  lying  quietly  upon 
his  back. 

STREPTOCOCCIC    FEVER:     OPERATION    IN 

When  the  infective  agent  in  puerperal  fever  is  the  strep- 
tococcus, as  demonstrated  by  its  appearance  on  the  eighth 
to  eleventh  day  and  proven  by  bacteriological  findings 
from  examination  of  a  little  of  the  intrauterine  debris, 
cureting  is  distinctly  contraindicated.  Since  in  the  milder 
forms  of  streptococcic  endometritis  the  leucocyte-wall  is 
the  barrier  against  systemic  infection,  use  of  the  curet  opens 
the  lymphatics  and  disseminates  the  pyogenic  bacteria; 
while  in  the  severer  type  the  leucocyte-zone  is  not  estab- 
lished but  the  streptococci  are  already  in  the  deeper 
strictures  where  they  cannot  be  reached  by  the  curet  and 
once  more  the  only  influence  of  that  instrument  is  to  help 
further  bacterial  invasion.  This  is,  therefore,  the  exact 
opposite  of  sapremia,  the  acute  fever  which  arises  on  the 
second  to  the  fifth  day  from  the  germs  of  putrefaction,  in 
which  instant  removal  of  the  decomposing  material  with 
the  Volkmann  spoon  or  large  curet  is  imperative  if  life  is 
to  be  saved.  All  that  is  necessary  in  streptococcic  infec- 
tion, then,  is  to  insert  a  small  strand  of  gauze  through  the 
os  to  insure  good  drainage  and  to  employ  internal  remedies 
to  assist  nature  to  carry  the  patient  through  the  acute  stage 
until  the  inflammation  localizes  itself,  after  which  pus  can 
be  evacuated  whenever  found. 


293  SURGICAL  THERAPEUTICS 

STRICTURE 

Urethral  stricture  may  sometimes  be  remedied  by 
gradual  dilation  with  sounds.  Forcible  dilation  (divulsion) 
with  an  Otis's  dilator  formerly  was  very  popular  but  has 
fallen  into  disrepute  of  late.  Internal  urethrotomy  is  much 
in  favor  with  some ;  but  when  gradual  dilation  is  not  possible 
or  the  patient  demands  early  relief  external  urethrotomy  is 
to  be  preferred.  A  large  sound  must  be  passed  every  week 
for  many  months,  regardless  of  the  discomfort. 

Strictures  Cured  by  Thiosinamin. — Some  most  re- 
markable results  have  been  reported  in  the  treatment  of 
strictures  (especially  of  the  esophagus)  by  this  drug. 
Therapeutic  Medicine  says:  Thiosinamin  is  a  white  crystal- 
line powder,  slightly  soluble  in  water,  easily  soluble  in 
alcohol  and  having  a  faint  odor  of  garlic.  It  has  been 
used  in  dermatology  to  promote  the  absorption  of  scars 
and  cicatrices  following  lupus,  psoriasis,  contractures, 
keloids,  etc.  It  has  also  been  used  in  the  treatment  of 
stenosis  of  the  esophagus.  It  is  hard  to  say  whether  the 
drug  actually  dissolves  or  absorbs  the  scar-tissue,  but  the 
good  effects  (which  may  also  be  due  to  the  scar  becoming 
elastic  and  yielding)  cannot  be  questioned. 

The  drug  is  given  subcutaneously  in  a  10- percent  aqueous 
solution,  a  syringeful  daily,  and  marked  improvement  gen- 
erally follows  in  a  month's  time.  It  may  be  used  in 
combination  with  sodium  salicylate  after  the  following 
formula: 

Sodium  salicylate i.o  (grs.  15       ) 

Thiosinamin i.o  (grs.  15       ) 

Water 10.0  (drs.    2  1-2) 

Injections  of  thiosinamin  near  a  scar  bring  about  marked 
improvement.  The  quantity  injected  each  time  is  a 
syringeful  containing  one  decigram  (i  1-2  grains)  of  the 
drug.  The  above  combination  of  thiosinamin  with  sodium 


SUPPURATION  299 

salicylate  is  practically  equivalent  to  Mendel's  fibrolysin, 
which  has  been  used  for  the  same  purpose. 

STYES 

Staphylococcus  infection  of  a  meibomian  gland  is  just 
the  same  as  any  other  boil  except  that  it  affects  the  mar- 
gin of  the  eyelid  instead  of  a  hair-follicle  on  the  surface  of 
the  body.  When  the  infection  first  becomes  apparent  it  is 
good  practice  to  apply: 

Yellow  oxide  of  mercury     0.5 

Lanolin    30.0 

By  using  this  as  an  inunction,  every  three  or  four  hours, 
suppuration  may  sometimes  be  prevented.  As  soon  as 
pus  forms  the  little  abscess  should  be  opened  and  the 
pus  carefully  evacuated.  Then  the  eyelid  (especially  at 
its  margin)  should  be  washed  frequently  with  saturated 
solution  of  boric  acid  to  prevent  infection  of  adjacent  glands 
and  follicles.  If  the  pain  be  severe  a  little  acetanilid  may 
be  prescribed:  one-third  of  a  gram  (5  grains)  three  or 
four  times  a  day  either  alone  or  with  half  a  decigram 
(gr.  3-4)  of  codeine.  As  a  rule,  styes,  like  boils,  are  found 
in  patients  with  bad  general  health;  so  iron,  strychnine 
and  arsenic  are  also  indicated,  with  the  use  of  a  small 
dose  of  epsom  salt  once  daily  until  the  "crop"  of  styes  is 
entirely  eradicated. 

SUPPURATION 

Calcium  Sulphide  in  Suppuration. — It  is  hard  to 
explain  how  a  purely  local  process  like  the  discharge  of 
pus  from  a  sore  may  be  affected  by  medicines  given  inter- 
nally; but  clinical  evidence  is  abundant  that  when  an 
infected  wound  is  discharging  a  thin,  watery,  nasty  pus 
and  persistently  refuses  to  granulate  and  heal,  the  use  of 
sulphide  of  calcium  will  soon  effect  a  marked  change. 
Under  its  influence  the  discharge  becomes  at  first  more 


300  SURGICAL  THERAPEUTICS 

b 

abundant  but  soon  diminishes  and  the  pus  becomes  thick 
and  creamy — the  "laudable  pus"  of  older  writers — the 
pus  which  is  present  upon  a  healthy  wound  granulating 
under  staphylococcus  infection  only.  The  best  dosage  is 
five  centigrams  (about  a  half  grain)  in  form  of  a  granule 
four  times  a  day. 

Deep  Glandular  Suppuration. — Quite  often  the 
deep  cervical  glands  become  infected,  particularly  in  weak 
children  who  have  had  measles  or  scarlet-fever.  In  such 
cases,  or  in  any  case  where  deep-seated  suppuration  is 
suspected,  sulphide  of  calcium  sometimes  acts  beautifully. 
Unless  the  pus  can  be  located  and  drainage  established, 
the  pain,  fever  and  constitutional  disturbance  may  become 
dangerous,  a  fatal  result  often  having  been  observed.  If 
one  centigram  (about  one-sixth  of  a  grain)  of  calcium  sul- 
phide be  given  every  hour  when  the  patient  is  awake,  the 
pain  soon  lessens,  the  fever  subsides,  the  abscess  becomes 
well  defined  and  may  be  opened  much  sooner — it  will  even 
"break"  of  itself  in  four  or  five  days  instead  of  the  two  or 
three  weeks  it  would  otherwise  require. 

SUTURE-MATERIALS 

Catgut. — Plain  catgut  is  used  for  all  ligations  and  for 
suturing  all  deep  structures  excepting  the  intestines. 

Chromicized  Catgut. — Some  surgeons  are  now  using 
chromicised  catgut  (twenty-day)  for  sewing  the  skin.  It 
certainly  is  very  satisfactory,  and  may  be  left  to  be 
absorbed  when  one  does  not  want  to  open  the  dressings 
for  weeks.  It  is  also  of  great  use  for  closing  the  cervix 
when  operating  for  lacerated  cervix  and  lacerated  perineum 
at  the  same  sitting;  the  ten-day  kind  being  used.  It  may 
be  employed  with  best  advantage  as  a  buried  suture, 
especially  in  operations  for  hernia. 

Silkworm-Gut. — For  suturing  the  skin  silkworm-gut 
has  been  found  to  be  le$s  irritating,  and  better,  than  any 


SYNOVITIS  301 

other  material  excepting  silver  wire.  It  is  sterilized  by 
boiling  with  the  instruments  for  20  minutes  at  time  of 
operation,  though  in  case  of  extreme  haste  it  may  be  simply 
washed  with  soap  and  water  and  immersed  in  alcohol  for 
two  minutes.  It  should  never  be  used  as  a  buried  suture. 
Stitches,  as  a  rule,  should  be  removed  from  the  seventh 
to  twelfth  day. 

Silver  Wire. — This  is  excellent  for  skin-sutures,  but  is 
expensive.  It  is  now  used  chiefly  for  the  repair  of  the 
cervix  and  perineum,  and  as  a  buried  suture  where  perma- 
nent apposition  is  to  be  maintained,  as  in  hernia. 

SYNOVITIS 

Inflammation  of  a  synovial  membrane  is  quite  common 
by  reason  of  infection  through  trauma,  gonorrhea,  etc. 
Various  pathological  conditions  are  generally  grouped  under 
this  head,  as  syphilis,  tuberculosis,  etc.,  but  these  are 
not  true  synovitis  but  specific  infections  characteristic  of 
each  cause  and  partaking  but  little  of  the  general  pathology 
found  in  true  synovitis — for  the  word  should  be  limited  to 
infection  by  pyogenic  microorganisms.  The  trouble  has 
been  that  the  older  pathologists  have  seen  a  tuberculous 
infection  of  the  synovial  membrane  (known  to  be  such) 
become  secondarily  involved  in  a  true  pus-producing  inflam- 
mation and  have  not  recognized  the  trouble  as  one  of  mixed 
infection.  Various  forms  described  in  text-books  are  like- 
wise dependent  upon  invasion  of  the  joint  by  pus-producing 
bacteria,  as  "metritic"  (staphylococcic  or  streptococcic), 
secondary  to  uterine  infection;  "puerperal"  (also  staphylo- 
coccic, streptococcic,  etc.),  occurring  after  child-birth; 
"scarlatinal"  (streptococcic),  associated  with  scarlet-fever; 
"exanthematous,"  etc.  Various  forms  of  bacteria  may, 
under  peculiar  circumstances, become  pus-producing  and  give 
rise  to  serious  synovitis,  as  the  bacillus  typhosus,  Pfeiffer 
bacillus(influenza),pneumococcus  and,  typically,gonococcus. 


302  SURGICAL  THERAPEUTICS 

Acute  Synovitis. — Acute  synovitis  may  be  treated  by 
compression  with  bandage  or  may  be  surrounded  by  the 
kaolin  and  glycerin  compound  (cataplasma  kaolini  U.  S. 
P.).  Later  lead  and  opium  may  be  used,  applied  hot, 
the  joint  covered  with  flannel  and  rubber  tissue  over  all. 
Later,  if  effusion  persist,  the  serum  may  be  removed  through 
a  large  needle.  The  skin  must  be  prepared  with  extreme 
care  (as  thoroughly  as  for  an  abdominal  section — indeed 
at  the  knee  more  carefully,  because  opening  of  the  knee- 
joint  is  more  dangerous  than  cutting  into  the  belly) ;  the 
needle  must  be  boiled  just  before  using;  and  the  hands 
must  be  perfectly  clean,  or  rubber  gloves  used.  After  with- 
drawal of  the  fluid  the  opening  must  be  closed  by  collodion 
or  a  pad  of  sterile  gauze.  Internally  one  may  use  the 
acetaniiid  compound  of  the  U.  S.  P.: 

Acetanilid    70.0 

Caffeine  . . 10.0 

Sodium  bicarbonate 20.0 

A  half-gram  (seven  grains)  may  be  ordered  three  times 
a  day,  either  alone  or  with  a  half  grain  of  codeine  sulphate. 
The  bowels  must  be  kept  open. 

Gonococcal. — When  the  gonococcus  infects  the  synovia 
(by  blood-transmission  or  otherwise)  it  produces  an  acute 
inflammation  which  has  erroneously  been  called  "gonor- 
rheal  rheumatism."  It  has  nothing  whatever  to  do  with 
rheumatism,  but  is  a  true  inflammation  due  to  the  action  of 
a  specific  microorganism.  It  may  be  treated  the  same  as 
any  other  acute  synovitis  until  it  is  seen  that  nature  cannot 
care  for  the  trouble,  the  recuperative  power  of  the  synovial 
:  embrane  being  overwhelmed,  and  pus  accumulates. 
Then  the  joint  must  be  opened  and  drained  under  strictest 
antiseptic  pr :  cautions  so  as  not  to  t  igraf t  a  staphylococcus 
infection  upon  the  membrane. 

Other  Forms. — Synovitis  dependent  upon  milder  in- 
fections, such  as  typhoid  germs,  the  bacillus  of  influenza, 


SYNOVITIS  303 

the  coccus  of  pneumonia,  etc.  (and  often  even  thegonococ- 
cus)  so  long  as  they  are  unmixed  with  true  pyogenic  poisons 
may  be  treated  by  less  energetic  measures:  rest,  cooling 
applications  like  lead  and  opium  wash,  icebags,  cataplasma 
kaolini,  and  alcoholic  lotions  such  as  tincture  of  arnica, 
tincture  of  camphor,  etc.  The  essential  element  is  enforced 
rest,  and  later  massage.  Internally  acetanilid  may  be  given 
to  control  pain,  aconitine  to  reduce  fever  (if  much),  codeine 
to  induce  sleep  if  pain  is  great  or  chloral  and  bromide  if 
there  is  not  much  suffering.  Salicylate  of  phenol  (salol) 
acts  well  in  many  cases. 

Staphylococcal. — Infection  by  staphylococcus  (acute 
inflammation  of  the  synovial  sac  following  an  ordinary 
punctured  wound)  is  somewhat  serious  if  the  joint  be  a 
large  one  like  the  knee  or  elbow.  Immediate  free  incision 
is  advisable,  followed  by  irrigation  with  large  quantities 
of  normal  salt  solution;  and  the  establishment  of  perfect 
drainage.  All  this  must  be  done  under  the  strictest  anti- 
septic precautions  to  prevent  engrafting  a  streptococcus 
infection  upon  the  less  virulent  type  already  present. 
Drainage  may  usually  be  discontinued  about  the  third  to 
sixth  day  unless  fever  and  great  swelling  continue.  In 
case  there  is  a  great  amount  of  injury  to  the  joint  it  is 
well  at  time  of  first  treatment  to  fill  the  joint  with  phenol- 
camphor  solution  (see  formula  elsewhere) .  In  many  cases 
a  useful  joint  may  be  expected. 

Streptococcal. — Infection  with  the  streptococcus  (ery- 
sipelas) is  a  most  serious  condition.  The  most  energetic 
antiseptic  treatment  must  be  employed  as  soon  as  the 
symptoms  (and  microscopic  examination  of  the  discharges) 
show  the  presence  of  this  type  of  inflammation.  Multiple 
incisions,  with  through-and-through  drainage  by  means  of 
gauze  strips,  injection  of  iodoform  emulsion,  free  use  of  the 
phenol-camphor  solution,  and  systemic  treatment  to  sus- 
tain the  power  of  nature  must  be  attended  to  promptly. 


304  SURGICAL  THERAPEUTICS 

In  many  ca  es  amputation  well  above  the  infected  areas 
offers  the  only  hope  of  life,  when  a  large  joint  is  implicated; 
an  1  when  indicated  there  must  be  no  delay. 

SYPHILIS 

As  soon  as  it  i3  seen  that  a  suspicious  sore  is  syphilis 
the  patient  should  be  put  upon  energetic  mercurial  treat- 
ment. One  of  the  best  prescriptions  for  secondary  syphilis 
i;: 

Hydrargvri  cum  creta grs.  20 

Pulv.  ipecac,  et  opii grs.  20 

Misce  et  ft  capsul.  No.  XX.  Sig. :  One  three  times 
a  day.  The  Dover's  powder  in  this  dosage  just  about 
equalizes  the  tendency  of  the  mercury  to  cause  diarrhea. 
When  there  is  need  of  extreme  haste  (as  when  the  eruption 
on  skin  is  conspicuous)  the  official  ointment  (unguentum 
hydrargyri)  may  be  rubbed  freely  in  the  groins  and  axilla 
twice  daily;  and  rarely  mercurial  baths  may  be  ordered. 

Recently  the  administration  of  mercury  hypodermically 
has  become  quite  popular,  and  it  does  seem  to  give  better 
results  than  the  older  methods,  though  it  is  attended  by 
some  pain.  Hebra's  solution  seems  to  be  most  popular: 
One-percent  solution  of  bichloride  of  mercury  is  added  to  a 
6-percent  solution  of  salt,  in  equal  quantities.  Of  this 
solution  from  20  to  30  minims  are  injected,  representing 
from  a  twelfth  to  an  eighth  of  a  grain  of  the  sublimate. 
The  injection  is  made  directly  into  the  body  of  the  gluteus 
maximus  muscle,  three  to  five  times  a  week;  or  every  day 
if  too  much  local  soreness  does  not  result,  abscesses  not 
infrequently  occurring,  even  when  great  care  is  taken  to 
clean  the  skin  with  alcohol.  From  twenty  to  thirty  injec- 
tions usually  cause  total  disappearance  of  all  symptoms. 
But  this  treatment  should  be  supplemented  by  a  year's 
use  of  good-sized  doses  of  mercury  internally.  The  most 
commonly  used  preparation  is  the  protoiodide  (hydrargyri 


SYPHILIS  305 

iodicLim  viride)  the  average  dose  of  which  is  one  centigram 
(gr.  1-6)  three  times  a  day. 

Iodine  and  iodides  are  given  entirely  too  indiscrimi- 
nately. They  are  chiefly  useful  in  tertiary  lesions:  joint 
affections,  gumatous  tumors,  chronic  ulcers,  etc.;  and  here 
they  frequently  have  to  be  given  in  extraordinary  dosage. 
It  is  usual  to  begin  with  two  grams  at  a  dose  (30  grains) 
three  times  a  day,  of  either  potassium  iodide  or  other  salt 
and  rapidly  increase  the  quantity  until  at  least  ten  times 
that  dosage  is  reached,  the  limit  being  the  tolerance  of  the 
stomach.  It  may  be  taken  in  Vichy  water,  in  milk,  in 
syrup  of  sarsaparilla  or  in  syrup  of  trifolium;  if  in  simple 
water  it  must  be  highly  diluted.  It  is  often  necessary, to 
continue  the  enormous  dosage  for  many  weeks,  particularly 
in  brain  tumor  of  syphilitic  origin;  occasionally  stopping 
for  a  few  days  to  let  the  stomach  rest. 

After  the  tertiary  symptoms  for  which  the  iodide  is 
given  have  disappeared,  it  is  well  to  let  the  patient's 
stomach  rest  for  a  fortnight  and  then  order  mercury  to 
be  taken  for  several  months.  "Mixed  treatment"  is 
wholly  irrational  and  cannot  be  too  strongly  condemned: 
the  patient  needs  either  mercury  or  the  iodides;  the  rem- 
edy to  be  selected  depends  upon  the  character  of  the 
lesions. 

Pilocarpine  in  Syphilis. — Wm.  J.  Robinson,  of 
New  York,  advocates  the  use  of  pilocarpine  as  an  adjuvant 
to  mercury  in  cases  in  which  the  system  has  become  sat- 
urated with  mercury  and  it  has  ceased  to  have  the  desired 
effect.  The  glands  continue  hard,  swollen,  and  tender, 
and  stomatitis  is  marked.  Gastrointestinal,  hepatic, 
renal  and  skin  activity  have  been  neglected.  The  pilo- 
carpine causes  the  elimination  of  mercury  that  was  stored 
up  in  the  salivary  glands  and  acting  as  a  toxic  body.  In 
the  bowels  and  kidneys  the  elimination  has  been  too 
great  for  the  organs,  and  the  pilocarpine  causes  the  skin 


306  SURGICAL  THERAPEUTICS 

to  act  and  carries  the  mercury  to  the  seat  of  the  skin 
lesions.  The  author  recommends  its  use  in  doses  of 
1-30  to  1-8 'grain,  two  or  three  times  a  day,  without  other 
drugs.  It  is  of  much  value  in  secondary  manifestations, 
and  is  a  most  remarkable  glandular  eliminant.  In  some 
cases  supersaturation  with  mercury  produces  intolerance 
of  the  drug,  and  the  use  of  pilocarpine  for  a  short  time 
will  enable  one  to  resume  mercury  with  excellent  effect. 

Syphilitic  Fever. — It  has  often  been  observed,  but 
is  frequently  forgotten,  that  syphilitic  fever  may  begin 
in  the  early  secondary  period  and  last  into  the  tertiary 
period.  It  may  or  may  not  be  accompanied  by  visceral 
manifestations,  especially  in  the  liver,  but  the  fever  does 
not  seem  to  be  dependent  on  these  lesions.  It  may  fall 
spontaneously  without  specific  treatment,  but  easily  re- 
turns. When  it  appears  late  in  the  disease  large  doses  of 
potassium  iodide  are  given  until  it  falls  by  lysis ;  but  in  the 
late  secondary  stage  of  lues  mercury  in  large  doses  checks 
it  much  more  promptly  than  does  the  iodides. 

Syphilis  in  Children — In  country  practice  as  well 
as  in  city  work  syphilis  of  childhood  is  often  unrecognized; 
and  especially  is  luetic  disease  of  bone  miscalled  "rheu- 
matism." This  trouble  almost  always  begins  as  a 
periosteal  thickening  with  some  tenderness;  rarely  with 
a  little  fever.  It  affects  the  heads  of  the  long  bones  first, 
as  a  rule,  but  sometimes  also  the  shafts;  as  the  thickening 
around  the  bones  increases  the  soft  ti-ssues  gradually 
become  infiltrated,  the  exudation  of  deposit  extending 
toward  the  surface  until  the  implicated  part  of  the  limb 
appears  much  swollen,  the  skin  finally  assuming  a  tense, 
shining  and  slightly  reddened  appearance,  with  much 
pain  and  decided  tenderness.  A  diagnosis  of  tuberculosis 
should  not  be  made  (there  is  absence  of  the  character- 
istic spindle-shape;  nor  should  it  be  mistaken  for  rheu- 
matism); there  is  but  little  impairment  of  joint-function 


TALMA  OPERATION  307 

save  that  due  to  the  swelling;  the  presence  of  Hutchinson 
teeth  or  of  iritis  makes  recognition  sure.  In  these  cases 
iodides  are  of  more  value  than  mercury;  they  should  be 
given  to  the  limit  of  tolerance.  A  child  of  three  years 
will  often  take  two  grams  (30  grains)  of  sodium  iodide 
three  times  a  day. 

Syphilitic  Periostitis. — This  is  usually  best  treated 
by  gently  rubbing  in  of  mercurial  ointment  twice  or  three 
times  a  day,  with  good  doses  of  calomel  internally;  and 
rest.  If  the  pain  becomes  severe  acetanilid  may  be  ordered 
in  half  gram  (8  grain)  doses. 

Syphilitic  Ulcers. — In  addition  to  the  internal 
treatment  local  measures  must  often  be  adopted.  If 
the  patient's  occupation  will  permit,  iodoform  powder 
is  the  best  to  use;  but  if  the  smell  renders  it  impossible 
bismuth  subiodide  may  be  substituted,  using  one  part 
of  that  drug  to  five  parts  of  powdered  boric  acid. 

TALMA  OPERATION:  HEPATIC  STIMULANT 
AFTER 

After  performance  of  the  Talma-Morrison  operation 
for  cirrhosis  of  the  liver  (suturing  the  great  omentum  to 
Glisson's  capsule  and  to  the  peritoneum)  it  is  well  to  give 
a  good  "hepatic  stimulant."  By  the  action  of  a  pill  or 
granule  containing 

Juglandin    0.005  (gr-  I"12  ) 

Quassin   o.oi     (gr.  1-6     ) 

Strychnine  arsenate 0.005  (»r-  I"I34) 

free  bowel  movement  may  be  secured  and  maintained, 
with  much  freer  flow  of  bile  than  usual.  It  is  best  to  begin 
.%  with  three  before  each  meal,  then  reduce  to  two  and  f  nally 
to  one.  Reaccumulation  of  ascites  may  be  prevented 
by  the  early  and  persistent  use  of  this  combination.  Boldine 
is  also  highly  recommended  in  these  cases,  the  dosage 


308  SURGICAL  THERAPEUTICS 

being  two  to  six  of  the  i-67-grain  granules  three  or  four 
times  daily. 

TESTICLE:    UNDESCENDED 

There  is  no  unanimity  of  opinion  as  to  the  most  favor- 
able age  for  operation  nor  as  to  the  technic  for  cryptorchid- 
ism.  One  should  consider  the  age,  whether  unilateral 
or  bilateral,  whether  pain  or  psychical  symptoms  are 
present,  presence  of  complications,  position  and  degree 
of  atrophy  of  the  undescended  testes.  The  non-opera- 
tive treatment  consists  in  massage  and  manipulation  with 
a  view  to  bringing  the  organ  into  the  scrotum,  o  a  truss 
above  the  gland  to  force  and  hold  it  down.  But  as  such 
testicles  have  been  proved  to  be  invariably  functionless 
the  best  treatment  is  excision,  with  careful  obliteration 
of  the  inguinal  canal  to  prevent  hernia. 

TETANUS 

The  first  thing  to  do  when  symptoms  of  tetanus  arise 
is  to  thoroughly  open  the  wound,  cauterize  its  every  part 
with  a  red-hot  Paquelin  cautery  and  pack  loosely  with 
iodoform  gauze.  Next  begin  with  chloral  and  bromides 
in  enormous  doses,  the  more  the  better;  four  grams  (60 
grains)  every  three  or  four  hours  frequently  are  required 
to  prevent  the  spasms.  Next  give  a  cathartic.  Then 
administer  pilocarpine  until  profuse  sweating  is  pro- 
duced— and  keep  it  up.  As  soon  as  the  tetanus  antitoxin 
is  obtained  give  it  in  large  doses  both  by  intraspinal  and 
subcutaneous  injections — from  60  Cc  to  80  Cc  a  day  to 
begin  with,  increasing  to  as  much  as  160  on  the  fifth  day. 
About  200  Cc  may  be  given  altogether  on  the  sixth  day, 
by  which  time  the  patient  will  be  either  dead  or  con- 
valescent. 

Tetanus  Cured  by  Spinal  Injection. — Very  recently 
successful  results  have  been  reported  in  the  treatment  of 


TOOTH-PASTE  309 

tetanus  by  spinal  injections.  Sixteen  Cc  of  cerebral 
fluid  are  withdrawn  and  3  Cc  of  the  fol  owing  solution 
injected:  i  1-2  grains  of  betaeucaine,  1-3  grain  of  morphine 
sulphate  and  3  grains  of  sodium  chloride,  with  sufficient 
water  to  make  3  1-2  ounces.  This  procedure  has  been 
repeated  four  times  in  the  cured  cases. 

TONGUE  FORCEPS  CONDEMNED 

No  anesthetist  should  use  tongue-forceps — they  are 
utterly  inexcusable.  If  the  tongue  drops  back  into  the 
throat  and  chokes  the  patient,  elevation  of  the  jaw  by 
placing  two  fingers  under  the  angle  on  each  side  and 
throwing  the  head  upward  and  backward  therewith, 
will  produce  instant  relief,  unless  there  be  accumulation 
of  mucus  in  the  throat,  in  which  case  the  head  must  be 
turned  to  one  side  and  a  swab  introduced  to  clean  out 
the  obstruction.  When  extensive  operation  is  to  be  done 
in  either  mouth  or  throat  a  strong  silk  thread  should  be 
passed  through  the  tongue  far  back  and  tied  in  a  huge 
loop;  this  will  enable  the  assistant  to  hold  the  tongue  up 
out  of  the  way  without  the  serious  mutilation  which  results 
from  the  use  of  forceps  on  the  tongue. 

TOOTH-PASTE 

Chlorate  of  potassium  in  any  strength  above  20  percent 
will  quickly  destroy  any  of  the  fungi  usually  found  in 
the  mouth,  including  the  germs  of  putrefaction.  A  most 
commendable  tooth-paste  is  this: 

Chlorate  of  potassium 50.0 

Precipitated  chalk 20.0 

Florentine  orris  root 15.0 

Glycerin 1 5.0 

Thymol    0.2 

Mix  and  make  a  paste;  a  little  more  glycerin  may  be 
added  if  necessary.  This  not  only  cleans  and  whitens 


310  SURGICAL  THERAPEUTICS 

the  teeth  but  stimulates  the  circulation  in  the  gums,  arrests 
fermentation  of  particles  of  food  left  between  the  teeth, 
Lweetens  the  breath  and  leaves  a  pleasant  taste  in  the 
mouth. 

TORTICOLLIS 

Acute  torticollis  (inflammatory  or  transient  spasmodic 
wry-neck)  may  sometimes  be  relieved  inside  of  ten  minutes 
by  the  following  method:  Put  a  large  handful  of  crushed 
capsicum  pods  in  a  pint  of  hot  or  cold  water  and  let  it 
stand  for  thirty-six  hours.  Soak  a  piece  of  gauze  in  this 
liquid  and  apply  to  the  affected  part,  covering  the  gauze 
with  oiled  muslin  or  oiled  silk.  This  never  blisters  but 
nearly  always  relieves.  Chronic  cases  can  be  cured 
only  by  division  of  the  scalenus  anticus  (rarely)  or  of  the 
sternocleidomastoid  (usually)  and  maintaining  the  head 
in  overcorrection  for  three  weeks. 

TRACHEOTOMY 

In  making  a  tracheotomy  one  should  avoid  making 
too  small  incisions,  as  bleeding  vessels  can  thus  be  more 
readily  brought  to  view  and  hemorrhage  more  easily 
controlled.  After  the  operation  the  inner  tube  should 
be  removed  and  cleaned  every  two  hours.  And  the  patient 
must  be  watched  every  moment  for  the  first  48  hours 
lest  mucus  accumulate  in  the  tubes  and  strangulation 
follow. 

TRANSFUSION  OF  BLOOD 

This  operation  is  again  coming  into  vogue,  and 
under  the  aseptic  technic  lives  are  being  saved  by  it. 
When  a  patient  has  bled  to  unconsciousness,  is  pulseless 
and  cold,  there  may  be  hope  of  restoring  life  if  the  source 
of  hemorrhage  has  been  found  and  the  leakage  stopped. 
The  radial  artery  of  the  donator  is  bared  and  opened 
and  a  small  glass  or  aluminum  tube,  sterilized,  introduced 


TRENDELENBURG  POSITION  311 

into  it  and  held  by  a  catgut  ligature  around  its  end;  a 
little  blood  being  allowed  to  flow  (to  determine  that  the 
current  has  been  established)  the  end  of  the  tube  is  closed 
and  all  wrapped  in  a  very  hot,  moist  towel.  The  basilic 
vein  of  the  donee  is  next  exposed  and  opened  as  for  vivi- 
section, the  distal  end  tied  but  the  proximal  left  open. 
The  end  of  the  vein  being  lifted  out  sufficiently,  blood 
is  permitted  to  flow  from  the  tube  long  enough  to  be  sure 
all  air  is  expelled,  and  then  (with  blood  still  running)  tfre 
end  of  the  tube  is  slipped  into  the  vein  and  tied  around 
with  gut.  Blood  is  permitted  to  flow  for  about  thirty 
minutes  when  the  vein  and  artery  are  each  closed  by 
ligation.  The  donor's  blood  will  drop  from  the  normal 
5  1-2  or  6  million  to  near  4,500,000  in  that  time  (hem- 
oglobin from  100  to  about  70)  while  the  donee's  will 
rise  correspondingly. 

TRENDELENBURG    POSITION:     A 
PRECAUTION 

In  performing  celiotomy  for  pelvic  troubles  where  the 
Trendelenburg  posture  is  employed,  the  incision  in  the 
abdominal*  wall  should  not  be  closed  while  the  patient 
is  in  that  position,  as  emphysema  of  the  abdominal  wall 
is  likely  to  follow  with  distressing  symptoms.  Meinert, 
of  Dresden,  has  known  eight  cases  of  this  kind,  and 
Leopold  alone  has  had  eight.  The  emphysema  occurs 
between  the  peritoneum  and  muscle  (the  peritoneum 
sometimes  being  easily  separated  from  the  muscle,  par- 
ticularly where  there  has  been  considerable  manipula- 
tion in  the  peritoneal  cavity),  and  in  the  subcutaneous 
areolar  tissue.  It  is  not  harmless,  but  it  increases  the 
rapidity  of  the  pulse,  causes  considerable  pain,  and  makes 
the  patient  restless.  It  also  may  extend  into  the  inguinal 
region,  or  even,  as  in  one  of  Leopold's  cases,  to  the  axilla. 
Healing  will  be  seriously  interfered  with.  The  trouble 


312  SURGICAL  THERAPEUTICS 

may  be  avoided  by  placing  the  patient  in  the  horizontal 
position  before  closing  the  abdomen.  The  greater  part 
of  air  admitted  to  the  belly  is  thus  expelled. 

TRIFACIAL  NEURALGIA 

In  the  surgical  treatment  of  trifacial  neuralgia  re- 
member: (i)  Avulsion  of  the  distal  branches  should  be 
the  first  operation.  (2)  Avulsion  with  ligation  of  the  com- 
mon and  external  carotid  arteries  should  be  second  choice. 
(3)  Removal  of  the  branches  of  the  nerve  (Lexer)  should 
be  the  third  choice.  (4)  Lexer's  method  combined  with 
that  of  LaPlace,  and  ligation  of  the  common  and  external 
carotid  arteries,  the  fifth.  (6)  Removal  of  the  ganglion 
and  neurectomy  of  the  distal  branches,  the  sixth.  (7) 
Removal  of  the  ganglion  combined  with  neurectomy 
and  ligation  of  the  common  and  external  carotid  arteries, 
the  seventh.  (8)  Neurotomy  or  else  the  injection  of  osmic 
acid  affords  only  temporary  relief.  (9)  Plugging  the  fora- 
minse  with  fragments  of  bone  cut  from  the  neighboring 
plate  will  prevent  regeneration  of  the  nerves  passing 
through  them.  (10)  The  method  of  Kroenlein  is  an 
innovation,  having  given  better  results  with  less  deformity, 
mortality,  loss  of  time,  motor  paralysis  and  less  risk  of 
loss  of  vision,  (n)  Relapse  occurs  after  intracranial 
operations,  but  in  such  cases  removal  of  the  ganglion  is 
supposed  to  have  been  incomplete.  (12)  Intracranial 
operations  for  the  removal  of  the  ganglion  should  be 
abandoned  because  of  the  high  mortality,  except  in  cases 
in  which  the  condition  is  desperate  and  other  measures 
have  failed.  (Ricketts.) 

TUBERCULOSIS:    SURGICAL 

Tuberculosis  from  Decayed  Teeth. — When  glands 
of  the  neck  are  the  site  of  tuberculous  enlargement  one 
should  not  only  examine  the  tonsils,  as  advised  by  Prof. 


TUBERCULOSIS:  SURGICAL  313 

Waugh,  but  also  the  teeth.  Very  often  a  tubercular 
peridentitis  acts  as  the  cause  of  the  enlargement  of  the 
glands,  especially  those  anterior  to  the  sternocleidomas- 
toid  muscle.  Removal  of  the  buccal  irritation  will  some- 
times cure  the  adenitis,  so  that  a  disfiguring  operation 
will  not  be  needed. 

Tuberculosis:  Genital. — Primary  tuberculosis  of  the 
genitalia  may  be  found  in  very  young  children,  Demme 
having  reported  cases  at  seven  and  thirteen  months. 
Other  authors  report  tuberculous  vulvar  tumors  in  a 
child  of  two  years  and  ulcefation  in  a  child  of  four  and 
one-half  years.  Tubal  tuberculosis  is  quite  rare,  how- 
ever. Carpenter's  method  of  combined  rectal  and  biman- 
ual  examination  revealed  genital  tuberculosis  in  all  cases 
ranging  in  age  from  fourteen  months  to  nine  years.  In 
the  practice  of  McNaughton  Jones  in  the  youngest  patient 
there  was  a  hard  mass  in  the  umbilical  and  hypogastric 
regions  with  the  right  ovary  adherent  to  it.  As  regards 
diagnosis,  the  most  important  thing  is  local  examination 
of  the  vulva,  vagina  and  portio  vaginalis,  assisted  by  a 
bimanual  examination  (through  the  rectum)  of  the  uterus 
and  adnexa  under  anesthesia;  a  microscopic  and  bac- 
teriologic  examination  of  some  portion  of  the  affected 
tissues  is  desirable,  if  obtainable,  as  would  be  a  similar 
examination  of  fragments  from  the  uterine  cavity  after 
curettage  in  older  patients.  The  presence  of  tuberculosis 
in  other  organs  adds  to  the  probability  of  the  suspected 
growths  being  tubercular.  The  appearance  of  the  ulcers, 
if  present,  is  similar  to  that  of  tuberculous  ulcers -else- 
where. Much  information  may  be  gained  by  recogni- 
tion of  tuberculosis  of  the  pelvic  peritoneum,  which  almost 
always  accompanies  similar  disease  of  the  genitals,  and 
which  may,  according  to  Hegar,  be  detected  on  internal 
examination  of  nodules  that  are  almost  pathognomonic. 
These  nodules  are  found  chiefly  on  the  posterior  surfaces 


314  SURGICAL  THERAPEUTICS 

of  the  sacrouterine  ligaments  and  frequently  the  tube  has  the 
form  of  a  rosary  with  very  hard  nodules.  A  nodule  in  the 
pars  uterina  is  also  a  fairly  reliable  sign  of  tuberculosis. 

Tuberculosis:  Ileocecal. — Those  who  have  given 
much  study  to  intraabdominal  surgery  will  quite  agree  with 
Hartmann,  who  says  it  is  not  at  all  uncommon,  there  being 
two  forms  of  the  disease:  (i)  Ulcerative  caseous  tubercu- 
losis, accompanied  by  pericecal  inflammation,  sometimes 
described  as  the  enteroperitoneal  form,  and  (2)  hyperplastic 
tuberculosis,  resembling  in  its  aspect  and  evolution  certain 
strictures  of  the  rectum,  formerly  known  as  inflammatory 
or  syphilitic,  and  now  shown  to  be  tuberculous. 

Etiologically  ileocecal  tuberculosis  is  equally  observed 
in  both  sexes.  The  disease  seems  to  present  its  maximum 
frequency  between  the  ages  of  twenty  and  forty  years. 
Before  twenty  and  after  forty  it  becomes  rare.  The  patient 
may  be  affected  with  lung  tuberculosis,  but  generally  to  a 
slight  degree,  or  even  not  at  all.  There  is,  between  local- 
ized cecal  tuberculosis  and  ordinary  tuberculous  enteritis, 
a  great  difference,  the  tuberculous  enteritis  appearing  in 
the  late  stages  of  lung  tuberculosis.  Infection  is  probably 
brought  about  by  ingesta,  and  localizes  itself  in  the  cecum 
because  of  the  stagnation  of  intestinal  contents  which  favors 
inoculation. 

Clinically  the  surgical  forms  of  ileocecal  tuberculosis 
manifest  themselves  chiefly  by  two  kinds  of  symptoms. 
Some  of  the  cases  exhibit  the  reaction  of  the  peritoneum 
and  its  surroundings,  simulating  appendicitis.  Others  are 
the  result  of  intestinal  stricture,  and  are  suggestive  of  neo- 
plasms, all  the  more  because  direct  examination  almost 
always  reveals  the  existence  of  a  tumor. 

In  the  enteroperitoneal  form  the  symptoms  are  those  of 
suppuration,  complicated  with  the  evolution  of  a  pulmonary 
tuberculosis.  Exceptionally  the  abscess  bursts  into  the 
peritoneal  cavity,  and  death  occurs  within  two  or  three  days. 


TUBERCULOSIS:  SURGICAL  315 

The  hyperplastic  form  has  an  insidious  onset,  with  loss 
of  appetite,  slow  digestion,  and  vague  disagreeable  sensa- 
tions in  the  right  iliac  fossa.  A  tumor  can  usually  be  felt; 
it  is  smooth  and  preserves  the  normal  shape  of  the  colon. 
The  disease  never  retrocedes,  and  unless  operated  for, 
invariably  proves  fatal.  Its  average  duration  is  two  and 
a  half  to  three  years. 

In  diagnosis  it  is  often  mistaken  for  neoplasm,  but  the 
progress  of  the  latter  is  usually  more  rapid,  and  the  tumor 
is  nodu'ar  and  irregular  in  outline.  The  enteroperitoneal 
form  can  readily  be  mistaken  for  appendicitis.  Actinomy- 
cosis  can  only  be  suspected  when  the  abdominal  walls  are 
rigid  and  board-like. 

The  treatment  of  ileocecal  tuberculosis  is  surgical,  the 
abdomen  must  always  be  opened.  Ca  es  of  glandular 
tuberculosis  with  subserous  nodules,  signs  of  slight  localized 
peritonitis,  and  without  symptoms  of  lesions  in  the  intestinal 
mucous  membrane,  may  be  cured  by  simple  exploratory 
celiotomy.  But  more  often  a  more  extensive  operation  is 
necessary.  It  is  never  necessary  to  remove  the  disease  in 
two  sittings,  as  the  obstruction  is  never  extensive.  It  is 
important  to  remove  with  the  cecum  the  glands  occupying 
the  ileocecal  angle,  which  are  often  enlarged  and  often 
caseous. 

After-treatment  is  essentially  that  of  tuberculosis  else- 
where :  outdoor  life,  good  food,  and  tonics  used  judiciously. 

Tuberculosis:  IntraperitoneaL — Late  investigations 
seem  to  support  Lawrence's  statements:  (i)  That  intraperi- 
toneal  tuberculosis  is  frequently  a  local  disease.  (2)  It 
probably  occurs  much  more  frequently  in  the  female  than 
in  the  male.  (3)  In  a  large  majority  of  cases  it  is  primarily 
visceral  and  the  general  peritoneum  is  secondarily  involved. 
(4)  The  surgical  treatment  is  rational,  sometimes  agreeably 
surprising  in  results,  and  again  bitterly  disappointing.  (5) 
In  this,  as  in  many  other  surgical  conditions,  early  diagnosis 


316  SURGICAL  THERAPEUTICS 

and  early  operation  will  bring  more  certain  results.  (6) 
In  this  condition  the  greatest  obstacle  to  overcome  is  the 
idea  that  it  is  a  secondary  condition.  (7)  No  case  of 
intraperitoneal  tuberculosis  should  be  denied  the  benfits 
of  operation,  no  matter  how  extensive,  as  long  as  there  is 
no  positive  pulmonary  or  pleuritic  involvement,  for  the 
reason  that  some  apparently  hopeless  cases  fully  recover. 
(8)  When  there  is  a  tubercular  peritonitis,  a  sequel  of 
tubercular  tubes,  ovaries  or  appendix,  the  primary  focus 
should  always  be  removed.  (9)  In  these  tubercular  cases 
the  mesenteric  glands  have  not  frequently  been  found  in- 
volved, and  when  they  are,  operation  accomplishes  very 
little  good.  (10)  In  tubercle  of  tubes  and  ovaries  the 
adhesions  are  usually  firm,  sometimes,  though  not  usually, 
very  vascular,  and  not  infrequently  involve  loops  of  the 
small  intestine ;  hence  the  greatest  care  is  necessary  to  avoid 
serious  injury  to  the  bowel  and  at  the  same  time  separate 
completely  all  adherent  surfaces  and  provide  complete 
drainage,  (n)  Drainage  is  the  factor  in  recovery,  when 
properly  carried  out. 

Tuberculous  Lymphadenitis.— In  the  management 
of  tuberculous  adenitis  the  internal  treatment,  and  the  local, 
are  rather  more  important  than  the  operative.  No  one 
should  persist  in  internal  medication  and  local  applications 
until  burrowing  abscesses  have  formed  or  the  glandular 
substance  has  broken  down  and  is  about  to  discharge 
through  the  skin;  for  such  treatment  would  lead  to  disaster: 
the  formation  of  indolent,  discharging  sinuses,  with  danger 
of  systemic  trouble  from  mixed  infection;  for  as  soon  as 
the  "cold  abscesses"  open  there  is  engrafted  upon  the  tuber- 
culous soil  the  staphylococcus,  even  if  not  the  streptococcus. 
Hence  it  is  very  easy  to  wait  too  long,  especially  as  the  pa- 
tient makes  little,  if  any,  complaint. 

But  so  long  as  the  tuberculous  focus  seems  limited  with- 
in the  capsule  (evidence:  non-adherence  to  surrounding 


TUBERCULOSIS:  SURGICAL  317 

tissues)  it  is  safe  to  abstain  from  surgical  interference, 
often  for  weeks  and  sometimes  permanently.  Non-operative 
treatment  consists  of  (a)  general  measures,  i.  e.,  increase 
of  food,  maximum  of  out-door  life  in  the  sunshine,  encour- 
agement of  proper  elimination  by  kidneys  and  bowels 
(excess  of  water  and  saline  laxatives  but  no  physic);  (b) 
the  administration  of  drugs  calculated  to  strengthen,  notably 
iron,  arsenic  and  strychnine  (the  "triple  arsenates  with 
nuclein"  is  an  excellent  combination),  creosote,  with  small 
quantities  of  alcohol  just  before  meals  (sweet  wines  or 
whisky  with  glycerin  or  syrup  just  before  eating  causes 
a  patient  to  take  more  food  than  without  the  alcoholic  agent) ; 
and  (c)  local  use  of  either  tincture  of  iodine  painted  on  the 
affected  gland — its  absorption  aided  perhaps  by  the  negative 
pole  of  a  galvanic  battery,  50  to  75  milliamperes — or  an 
ointment  of  ichthyol  in  lanolin.  Massage,  aside  from  the 
gentle  rubbing  in  of  ointment,  must  never  be  permitted; 
rupture  of  the  capsule  of  a  non-inflamed  tuberculous  gland 
is  likely  to  have  early  pulmonary  consumption  as  a  result. 
As  soon  as  the  gland  softens,  or  becomes  adherent,  it  should 
be  excised. 

Tuberculous  Peritonitis. — We  have  been  taught  to 
believe  that  simple  abdominal  section  with  considerable 
manipulation  of  the  viscera  and  evacuation  of  the  ascitic 
fluid  will  cure  tuberculous  peritonitis.  But  while  it  is 
true  that  certain  patients  have  apparently  been  cured  by 
such  mild  procedures,  a  much  larger  number  have  gone 
on  to  fatal  termination.  The  mistake  has  been  made  of 
treating  a  symptom  (ascites)  instead  of  the  disease.  Radical 
removal  of  every  local  deposit  of  tubercle  wherever  found 
is  the  only  certain  cure.  In  a  small  percentage  of  cases  it 
cannot  be  found;  here  the  only  resource  is  irrigation,  mani- 
pulation and  closure.  In  a  larger  percentage  of  cases  the 
lesions  are  so  numerous  or  so  situated  that  they  cannot 
be  removed ;  here  gentle  rubbing  of  the  affected  surfaces  with 


318  SURGICAL  THERAPEUTICS 

gauze  may  do  good.  In  all  cases,  whether  the  local  focus 
be  removed  or  not,  the  most  energetic  constitutional  treat- 
ment must  be  instituted;  forced  feeding  and  tonics  do  fully 
as  much  in  abdominal  tuberculosis  as  in  pulmonary.  But 
unless  the  primary  seat  of  the  disease  is  found  and  the  source 
of  trouble  removed  a  guarded  prognosis  should  be  given 
regardless  of  how  much  the  patient  may  gain  after  operation. 
Medication  is  the  same  as  that  for  any  other  abdominal 
section  during  the  first  few  days,  and  then  the  same  as  for 
phthisis. 

Tuberculous  Testicle:  X-Ray  for* — In  a  late  paper 
Professor  W.  B.  De  Garmo,  of  the  New  York  Post- Graduate 
Medical  School,  reports  what  he  believes  to  be  the  pioneer 
case  of  tuberculosis  of  the  testicle  successfully  treated  by 
the  x-ray.  The  patient  was  a  robust  man,  age  56,  who  had 
always  enjoyed  good  health.  He  had  gonorrhea  twenty- 
five  years  previously,  but  denied  syphilitic  infection.  For 
the  past  five  years  the  left  testicle  gradually  increased  in 
size  and  was  the  seat  of  considerable  pain.  During  the  last 
eight  months  there  was  gradual  decrease  in  weight.  The 
testicle  was  the  size  of  an  orange,  hard,  nodular  and  tender 
to  pressure.  After  several  months'  delay  the  patient  con- 
sented to  removal  of  the  testicle,  which  was  done,  and  on 
examination  it  was  found  to  be  tuberculous.  About  two 
months  later  the  right  testicle  became  involved.  The 
patient  refused  to  have  it  removed,  and  the  x-ray  was  ap- 
plied. When  treatment  was  begun  the  testicle  was  several 
times  its  normal  size  and  had  the  clinical  appearance  of 
tuberculosis.  One  hundred  and  twenty-six  treatments  of 
ten  minutes  each  were  given  within  a  period  of  ten  months. 
A  medium  tube  was  used  at  about  10  inches.  The  first 
application  relieved  the  pain.  Swelling  and  tenderness 
gradually  subsided,  until  at  the  last  treatment  the  testicle 
was  apparently  in  a  "normal  condition."  But  in  testicles 
thus  treated  the  spermatozoa  are  rendered  sterile. 


TUBERCULOSIS:  SURGJCAL  319 

Surgery  of  Pulmonary  Tuberculosis. — A  number 
of  cases  have  been  recorded  in  which  a  localized  abscess  of 
the  lung,  of  tubercular  origin  but  of  staphylococcus  engraft- 
ment,  has  been  opened  and  drained,  with  recovery.  But 
it  has  remained  for  Lionel  Strutton,  of  Kidderminster, 
England,  to  make  phthisis  pulmonalis  an  exclusively  sur- 
gical disease  by  removal  of  an  entire  lung.  The  patient, 
a  female,  age  28,  had  definite  signs  of  disease  at  the  right 
apex;  the  illness  was  of  four  years'  duration;  in  the  last 
year  and  a  half  there  was  a  continuous  cough  with  expectora- 
tion and  night-sweats.  There  was  dulness  as  far  as  the 
third  rib,  tubular  breathing  and  crepitant  rales;  but  no 
apparent  involvement  of  the  opposite  side,  so  under  ether 
anesthesia  an  incision  three  inches  long  was  made,  with 
its  center  over  the  third  rib,  two  inches  from  the  sternum; 
about  four  inches  of  the  third  rib  was  removed. 

On  opening  the  pleura  the  latter  was  found  everywhere 
adherent;  the  adhesions  were  loosened  carefully  with  the 
hand  as  far  as  the  third  rib;  this  portion  of  the  lung  was 
surrounded  with  a  serre-noeud  and  was  cut  away,  leaving  a 
stump  of  about  the  size  of  a  five-shilling  piece.  For  the  first 
twenty-four  hours  the  patient  was  in  a  condition  of  collapse. 
During  the  next  few  days  there  was  considerable  hemor- 
rhage both  from  the  wound  and  from  the  mouth.  On  the 
seventh  day  hemorrhage  ceased,  but  symptoms  of  sepsis 
intervened  which  required  a  counter-opening  in  the  back, 
through  which  a  large  drainage  tube  was  passed.  The  wire 
came  away  on  the  eighteenth  day  and  recovery  was  unevent- 
ful. The  wound  was  entirely  healed  three  months  later. 
Soon  after  this,  all  cough  and  expectoration  ceased.  The 
excised  portion  of  the  lung  was  tuberculous  and  con- 
tained a  cavity.  Six  months  later  the  patient  was  reported 
well. 

Surgical  Tuberculosis. — In  all  forms  of  surgical 
tuberculosis  (bone-destruction,  peritonitis,  nephritis,  sal- 


320  SURGICAL  THERAPEUTICS 

pingitis,  etc.)  the  following  plan  should  be  rigidly  enforced: 
(i)  The  " open-air  treatment"  should  be  organized  to 
meet  the  circumstances  and  requirements  of  the  particular 
case.  (2)  In  every  case  the  patient's  power  of  resistance 
to  the  disease  should  be  periodically  measured  by  suitable 
blood  examination.  (3)  When  resistance  is  found  low 
and  there  is  no  evidence  of  an  excessive  autoinoculation, 
use  should  be  made  of  therapeutic  inoculations  of  Koch's 
new  tuberculin  in  doses  that  are  accurately  controlled  both 
as  regards  their  amount  and  repetition  by  examination 
of  the  blood.  (4)  In  cases  where  there  is  evidence  of 
excessive  autoinoculation  absolute  rest,  with  complete 
fixity  of  the  diseased  part,  should  be  prescribed.  £5) 
When  it  is  evident  that  the  diseased  area  is  circumscribed 
and  cut  off  from  the  circulation  of  tissue-fluids,  efforts  should 
be  made  to  improve  the  circulation  through  the  diseased 
area.  The  means  at  our  disposal  are  fomentations,  the  use 
of  certain  mild  irritants,  e.  g.,  liniment  of  iodine,  light 
therapy,  general  massage  and  local  massage  with  carefully 
regulated  movements.  (6)  Operative  procedures  should 
be  directed  to  the  removal  of  the  dead,  inert  material, 
whether  pieces  of  bone  or  collections  of  pus,  and  should  be 
conducted  with  the  most  scrupulous  aseptic  precautions. 
(7)  The  most  careful  attention  should  be  paid  to  diet  and 
digestion,  proper  elimination  through  the  alimentary  canal 
being  of  exceedingly  great  importance.  (8)  Remedies 
proper  for  pulmonary  tuberculosis  are  to  be  prescribed  with 
just  as  much  thoughtfulness  as  in  the  more  acute  forms  of 
tubercular  disease. 

TUMORS 

The  word  "tumor"  is  loosely  used  among  surgeons  to 
express  any  sort  of  enlargement  or  swelling  of  a  part, 
whether  the  result  of  inflammatory  action  or  not.  Strictly 
speaking  a  tumor  is  a  new  growth,  not  the  result  of  inflam- 


TYMPANITES  321 

mation  or  hyperplasia.  Most  authorities  adopt  the  classi- 
fication giver  by  Gould's  Medical  Dictionary — based  in 
great  part  on  the  blastodermic  origin  of  the  dominant 
tissue  of  the  growth — as  follows: 

A,    MESODERMIC  TUMORS 

Round-cell  \  ^Tge 
I  Small 
I  Lymphosarcoma 


1.  Sarcoma 


2.  Fibroma 

j  Soft 

3.  Myxoma 

4.  Lipoma 


Spindle-cell       4  Large 
I  Small 
Giant-cell 
Melanotic 
Alveolar 
Endpthelioma 
Angiosarcoma 
Cylindroma 
Chloroma 
Psammoma 


,  j  Hyaline 

5.  Chondroma         -j  Fibrous 

j  O.  durum  or  O.  eburneum 

I  O.  spongiosum  or  O.  medullare 

]  Telangiectatic 

7.  Hemangioma      -J  Cavernous 

8.  LymphangiomaJ  Simple 


9.  Myoma  \  o. 

j  Rhabdomyoma 

B.     ECTODERMIC  AND  ENTODERMIC  TUMORS 

1.  Glioma 

N.  myelinicum 

2.  Neuroma  •{  N.  amyelinicum 

Adenoma  (  Tubular 

I  Racemose 

3.  Epithelioma        (  Carcinoma  \  Squamqus 

;  Cvlinc" 


IN. 

1N- 
I  Ad 

Cai 

j  !  Cylindric 

L  Glandular 
'  Epithelial  cystoma  \  C.  simplex 

I  C.  papilhferum 


C  TERATOID  TUMORS  OR  TERATOMATA 

1.  Dermoid  cysts 

2.  Cholesteatoma 

The  treatment  of  each  will  be  discussed  under  their 
distinctive  titles. 

TYMPANITES 

The  distressing  bloating  of  the  abdomen  which  follows 
some  intraperitoneal  operations  and  which  is  so  prominent 


322  SURGICAL  THERAPEUTICS 

in  peritonitis  may  frequently  be  controlled  by  half  a  milli- 
gram (1-134  grain)  of  physostigmine  every  two  or  three 
hours.  It  is  claimed  by  Abbott  that  the  same  dose  of 
picrotoxin  will  have  a  similar  effect.  • 

Alum  for  Tympanites.  —Gaseous  distension  of  the  colon 
is  often  distressing  after  abdominal  operations.  A  good 
treatment  consists  of  dissolving  one  ounce  of  alum  in  half 
a  gal  on  of  warm  water  and  injecting  with  a  high  rectal  tube. 

Ergotin  for  Tympanites. — To  reduce  the  distressing 
distension  of  the  abdomen  following  intraperitoneal  opera- 
tions the  hypodermic  use  of  ergotin  is  advisable.  If  ergot 
is  given  by  the  mouth  it  will  almost  invariably  excite  vomit- 
ing— which  will  increase  the  distension.  So  two  drams  of 
the  fluid  extract  may  be  given  by  rectum  and  repeated  in 
two  hours;  or  1-4  grain  of  ergotin  may  be  injected  into  the 
buttock  or  thigh — not  the  arm,  as  abscesses  sometimes 
foVow  its  use. 

TYPHOID  SPINE 

Inflammation  of  the  joints  following  typhoid  fever  has 
long  been  recognized  as  a  surgical  complication  or  sequel 
of  that  disease,  but  has  only  of  late  been  known  to  be  due 
to  infection  of  the  synovial  membrane  or  the  bone  by 
the  Eberth  bacillus — one  of  the  germs  which  become  pyo- 
genic  under  certain  conditions.  The  knee  has  been  the 
joint  most  often  involved,  but  of  late  it  has  been  shown 
that  the  spine  may  also  be  implicated;  the  patient  com- 
plaining of  pain  in  the  back,  with  its  accompanying  dis- 
ability. An  intensely  neurotic  condition  develops,  with 
paresthesias,  anesthesias,  spasm  or  atrophy  of  muscles, 
general  weakness — in  fact,  a  condition  so  like  "traumatic 
spine"  or  the  neurasthenia  which  follows  a  severe  injury 
that  the  condition  has  usually  been  regarded  as  of  central 
nervous  origin  and  the  spondylitis  overlooked.  Indeed, 
there  may  be  little  to  attract  attention  to  the  bones  or 


ULCERS  323 

joints  of  the  spine — stiffness  and  sensitiveness  with  pain, 
these  being  all  of  the  local  signs  in  some  cases ;  but  in  the 
more  serious  ones  there  may  be  actual  deformity,  and 
examination  with  the  x-ray  may  show  some  deposit  around 
the  site  of  local  infection.  Primarily  the  focus  is  limited 
to  the  periosteum  in  most  cases,  but  the  interior  of  the 
bone  may  be  the  locus  minoris  resistentia  or  may  become 
the  seat  of  secondary  infection  very  early  in  the  disease. 
In  the  more  fortunate  cases,  treated  by  proper  quietude  and 
supportive  measures,  the  disease  disappears  without  sup- 
puration— a  mere  typhoid  periostitis  or  osteomyelitis ;  but  in 
the  worst  ones  pus  forms  and  may  cause  serious  trouble 
unless  recognized  and  evacuated.  When  the  focus  of  sup- 
puration can  be  located,  the  proper  treatment  is  to  open  the 
abscess,  curet  away  the  diseased  bones  and  pack  with 
gauze,  the  utmost  care  being  taken,  both  at  operation  and 
in  the  subsequent  drainage,  to  maintain  the  strictest  asepsis, 
so  as  to  prevent  the  engrafting  of  a  staphylococcus  or  strepto- 
coccus infection  upon  the  minor  pyogenic  one  already 
present.  By  such  treatment  extensive  deformity  may  be 
prevented.  These  abscesses  have  heretofore  been  con- 
founded with  those  originating  as  a  tuberculous  spondylitis. 
Internal  medication  should  be  supportive,  iron,  arsenic, 
strychnine  and  wine  being  particularly  useful. 

ULCERS 

Some  ulcers  become  very  chronic,  especially  those  of 
the  legs  dependent  upon  ruptured  varicose  veins.  When 
they  are  irritable,  soothing  applications  are  indicated, 
oxide  of  zinc  ointment  being  a  favorite  with  many  doctors. 
Others  prefer  an  ointment  of  carbonate  of  lead,  the  lead 
being  rubbed  up  with  linseed  oil;  but  if  the  ulcerated  sur- 
face be  extensive  and  granulations  not  active,  lead  poisoning 
may  occur.  When  the  ulcer  is  indolent  various  applica- 
tions have  been  recommended  to  promote  healing — all 


324  SURGICAL  THERAPEUTICS 

with  more  or  less  success — generally  less;  for  these  ulcers 
are  very  hard  to  heal  without  operative  treatment — re- 
quiring at  least  curettage. 

Bismuth  benzoate  has  been  much  praised  to  stimulate 
the  healing  process;  the  ulcer  being  cleansed  by  use  of 
hydrogen  dioxide,  or  one  in  1000  sublimate,  or  one  in  40 
carbolic  acid,  is  dried  by  gently  applying  absorbent  cotton 
or  gauze  (better),  the  surface  is  dusted  freely  with  the 
bismuth,  covered  with  dry  gauze  and  cotton  held  in  place 
by  adhesive  strips  rather  than  bandage.  Some  burning 
follows  the  application,  but  this  subsides  in  a  few  minutes. 
The  dressing  has  to  be  reapplied  every  day. 

Nitric  acid  is  also  used  to  stimulate  these  indolent  ulcers: 
10  to  30  drops  to  the  ounce;  and  sulphuric  acid  has  been 
likewise  employed.  When  there  is  too  free  discharge 
gallic-acid  ointment  (which  see)  has  been  lauded  for  many 
years.  When  the  granulations  are  exuberant  they  may  be 
best  cauterized  by  application  of  a  piece  of  blu6  vitriol — 
copper  sulphate.  Occasionally  the  best  treatment  is  to 
scrape  away  all  granulations,  after  injecting  cocaine  behind 
the  raw  surfaces,  and  disinfect  by  saturated  solution  of 
potassium  permanganate,  dry  the  surface  with  gauze,  cover 
deeply  with  powdered  boric  acid,  apply  gauze  wrung  from 
phenol-camphor,  protect  with  oiled  silk  and  put  on  a 
Martin  bandage  over  the  leg  or  arm.  This  dressing  must 
be  changed  every  forty-eight  hours  for  a  long  time.  When 
all  local  (non-operative)  measures  fail,  in  persistent  leg 
ulcers  the  Schede  operation  should  be  advised  as  it  fre- 
quently gives  most  brilliant  results  in  cases  which  have 
persisted  for  years.  Most  careful  attention  must  be  paid 
to  building  up  the  general  health,  if  impaired,  arsenic 
being  especially  beneficial  if  used  for  a  long  time. 

Calcium  Iodide  for  Ulcer  of  the  Leg — This  remedy, 
has  proved  curative  in  ulcers  which  have  for  years  stub- 
bornly resisted  all  kinds  of  treatment.  Patients  who  have 


ULCERS  325 

without  avail  been  simply  saturated  with  potassium  iodide, 
in  a  week  or  two  show  clean  granulating  surfaces,  and 
the  ulcers  have,  in  almost  all  cases,  healed  up.  In  all  cases 
the  induration  around  the  ulcers  soon  diminishes  or  en- 
tirely disappears.  A  few  cases  of  syphilitic  necrosis  of  the 
nasal  bones  have  derived  considerable  benefit  from  its 
administration  and  great  relief  is  to  be  obtained  in  head- 
aches associated  with  syphilis.  The  dose  given  in  all  cases 
is  two  grains  in  mixture  three  times  a  day,  and  there  does 
not  appear  to  be  any  increased  advantage  from  augmenting 
the  dose.  Any  mild  external  application,  without  distinc- 
tion, seems  efficacious;  in  most  cases  it  is  perhaps  best  to 
use  a  mild  mercurial  or  iodoform  ointment. 

Dusting  Powder  for  Ulcer  of  Leg — As  a  dusting 
powder  for  varicose  or  eczematous  ulcers  of  the  leg  this 
formula  may  be  tried: 

Dry  aluminum  acetate 32.0 

Balsam  of  Peru    8.0 

Borated  talcum    40.0 

This  may  be  applied  freely  and  covered  by  antiseptic  gauze, 
cotton  and  bandage;  or  gauze  strips,  paraffined,  may  be 
substituted,  the  powder  adhering  well  to  these. 

Inflammation  of  Ulcers. — Chronic  ulcers,  particularly 
varicose  ulcers  of  the  leg,  sometimes  take  on  an  acute  inflam- 
mation, they  and  the  surrounding  parts  becoming  exceed- 
ingly painful.  A  very  useful  application  in  such  cases  is 
digitalis.  A  teaspoonful  of  the  dried  leaves  thrown  into  a 
pint  of  boiling  water  makes  a  strong  infusion  in  which 
gauze  may  be  soaked  and  applied  to  the  inflamed  surface, 
acting  better  if  covered  by  rubber  tissue.  After  some  hours' 
treatment  by  this  a  kaolin-glycerin  paste  may  be  substituted. 
Medicines  for  Ulcers. — In  the  treatment  of  ulcers 
not  all  of  one's  attention  should  be  directed  to  the  local 
measures — internal  medication  is  often  of  great  importance. 
Chronic  ulcers  are  frequently  associated  with  a  "run-down" 


326  SURGICAL  THERAPEUTICS 

condition,  an  anemia  which  requires  both  iron  and  strych- 
nine. To  each  teaspoonful  dose  of  the  National  Formulary 
"elixir  of  quinine,  iron  and  strychnine"  may  be  added  three 
or  four  drops  of  the  official  liquor  acidi  arseniosi ;  to  be  taken 
three  times  daily.  Better  still  and  much  more  convenient, 
as  well  as  more  effective,  are  the  arsenates  of  iron,  quinine 
and  strychnine,  with  nuclein.  In  some  cases  attended  with 
free  discharge,  echinacea  seems  to  do  much  good — a  tablet 
of  a  half  grain  of  solid  extract  four  times  a  day  being  a 
pleasant  mode  of  administration  of  such  an  unpleasant 
drug.  Stillingin,  one  centigram  (1-6  grain),  may  be  given 
simultaneously. 

Syphilitic  Ulcers, — Ulcers  of  syphilitic  origin  may  be 
well  treated  by  local  use  of  iodoform.  After  thorough 
cleaning  the  ulcerated  surface  may  be  covered  by  powdered 
iodoform  and  gauze  applied.  But  as  the  iodoform  is  apt 
to  cake,  most  genitourinary  surgeons  prefer  to  use  some- 
thing like  this: 

Iodoform 1.5  (grs.  20) 

Oil  of  eucalyptus   16.0  (oz.  1-2) 

Apply  on  gauze  and  cover  with  oiled  silk.  When  the  pa- 
tient must  be  on  the  street  bismuth  subiodide  may  be 
substituted  for  the  iodoform,  on  account  of  the  unpleasant 
odor  of  this  drug;  but  it  is  not  nearly  so  satisfactory  as  is 
iodoform  which  more  readily  gives  up  its  iodine. 

Ulcers  of  the  Leg. — There  are  few  things  more  trying 
to  the  patience  of  the  surgeon  than  the  management  of 
chronic  ulcers  of  the  leg,  particularly  when  the  patient  can- 
not or  will  not  remain  quiet  and  give  the  leg  the  benefit 
of  rest  and  elevation.  For  the  latter  cases  the  following 
line  of  treatment  will  often  be  found  satisfactory:  Inject 
cocaine  solution  at  several  points  around  the  ulcer;  when 
insensitive,  thoroughly  scrub  with  brush  and  antiseptic 
soap  with  hot  water,  and  scrape  away  any  hypertrophic 
granulations  present  with  a  sharp  spoon  and  touch  the 


ULCERS  327 

whole  surface  with  nitrate  of  silver.  The  leg  is  then  shaved 
and  washed  and  a  moderately  thick  layer  of  warm  paste 
applied  to  the  leg  by  an  ordinary  brush,  the  paste  coming 
just  to  the  margin  of  the  ulcers  and  not  on  to  it.  The 
composition  of  this  paste  (Unna's  formula)  is: 

Zinc  oxide    30  parts 

White  gelatin   40  parts 

Glycerin   50  parts 

Water    90  parts 

Mix,  after  soaking  and  heating. 

This  is  to  be  applied  while  still  warm.  The  surface  of  the 
ulcer  is  next  dried  and  covered  with  powdered  iodoform, 
abundantly.  A  quantity  of  bichloride  gauze  is  now  placed 
over  and  around  the  ulcer  and  a  roller  bandage  firmly 
wound  around  the  leg,  beginning  at  the  toes  and  ending 
several  inches  above  the  ulcer.  As  soon  as  the  gelatin 
has  dried,  the  patient  can  be  allowed  to  go  about  his  busi- 
ness. This  dressing  must  be  removed  on  the  third  day 
and  the  ulcer  cleaned  with  hydrogen  dioxide,  the  surround- 
ing surface  being  washed  with  soap  and  water,  another 
coating  of  the  paste  applied,  and  the  iodoform  gauze  and 
bandage  used  as  before.  This  mode  of  dressing  must  be 
repeated  every  third  day  as  long  as  there  is  much  dis- 
charge, but  as  this  diminishes  the  interval  can  be  lengthened 
until  as  much  as  a  week  may  safely  intervene.  This  treat- 
ment is  perfectly  protective,  exerts  an  even  pressure  over 
the  leg  much  more  effectively  than  the  old  way  of  applying 
a  rubber  bandage,  while  the  paste  prevents  the  septic 
discharge  from  coming  in  contact  with  the  healthy  skin. 
After  the  first  application  there  is  no  pain  attending  the 
treatment. 

Ulcers  of  the  Mouth. — Persistent  ulcers  of  the 
mouth,  not  of  syphilitic  origin,  are  best  treated  by  burning 
with  stick  nitrate  of  silver,  with  a  saturated  solution  of 
potassium  chlorate  containing  a  little  thymol  as  a  mouth- 


328  SURGICAL  THERAPEUTICS 

wash.  The  burning  may  be  repeated  every  two  days; 
but  few  treatments  will  be  needed.  Ulcers  which  persist 
in  spite  of  this  treatment  are  (i)  tuberculous,  (2)  syphilitic 
or  (3)  cancerous,  and  demand  careful  investigation;  excision 
of  a  small  piece  of  involved  tissue,  under  cocaine  anesthesia, 
is  justifiable  in  suspicious  cases,  for  microscopic  ex- 
aminations. 

URACHUS 

Cysts  of. — In  the  differentiation  of  intraabdominal 
growths  a  tumor  in  the  midline  between  pubes  and  umbili- 
cus must  always  be  carefully  examined  to  exclude  a  cyst 
of  the  urachus.  If  it  has  not  been  discharging  at  the  navel 
it  might  easily  be  mistaken  for  an  ovarian  tumor,  a  fibroid 
of  the  uterus,  a  growth  in  the  mesocolon,  or  a  distended 
bladder.  But  almost  always  there  has  been  some  kind  of 
a  discharge  from  the  umbilicus;  urine,  if  the  urachus  be 
still  open  into  the  bladder,  a  milky  fluid,  if  there  be  a  true 
cyst  of  the  urachus.  When  there  is  a  discharge  present, 
it  must  be  identified  beyond  question,  for  besides  urine  and 
cyst-contents  there  may  be  discharged  (i)  pus  from  an  ab- 
scess in  (a)  the  abdominal  wall,  (b)  the  fallopian  tube,  (c) 
an  appendical  inflammation,  (d)  a  fecal  fistula  or  (e)  some 
other  source;  (2)  contents  of  a  dermoid  cyst,  or  (3)  secre- 
tion from  a  moist  eczema  of  the  umbilicus. 

UREA:    TO  INCREASE  EXCRETION  OF 

In  many  surgical  conditions  there  is  a  deficient  excre- 
tion of  urea.  One  of  the  most  highly  recommended  remedies 
for  this  is  boldine,  the  alkaloidal  active  principle  of  boldo 
leaves.  This  is  said  to  speedily  increase  the  production 
of  urea  and  expedite  the  excretion  of  solids  by  the  kidneys. 
The  usual  dose  is  one  milligram  (1-67  grain)  every  three 
hours,  or  two  milligrams  four  times  a  day.  It  may  be 
prescribed  also  when  there  is  an  insufficient  flow  of  bile. 


URETHRA  329 

UREMIA 

Symptoms  of  uremia  appearing  after  operations  (parti- 
cularly those  on  the  kidney)  demand  immediate  and  vigor- 
ous treatment.  Probably  the  best  thing  to  do  is  to  begin 
immediately  with  one  milligram  (1-67  grain)  of  elaterin, 
every  hour  by  mouth  and  continued  until  very  free  watery 
bowel-movements  are  obtained;  and  with  it  one-half  centi- 
gram (1-12  grain)  of  calomel,  as  this  drug  In  such  doses 
stimulates  kidney-action.  At  the  same  time  nitrate  of 
pilocarpine  should  be  injected  hypodermically  (dose  one 
centigram,  or  1-6  grain)  every  hour  until  profuse  sweating 
results.  If  coma  or  convulsions  occur,  hypodermoclysis 
must  be  resorted  to — one  liter  (a  quart)  of  normal  salt  solu- 
tion to  be  thrown  into  the  cellular  tissue  of  the  breasts 
or  buttocks  and  repeated  in  two  hours  if  necessary.  One 
grain  of  sulphate  of  sparteine  every  three  hours  is  highly 
recommended  hypodermically. 

URETHRA 

Foreign  Body  in  Urethra* — It  is  not  often  necessary 
to  make  an  external  urethrotomy  to  remove  a  foreign  body 
from  the  urethra,  unless  it  be  beyond  the  "cut-off"  muscle. 

Schroeter  has  been  successful  with  the  following  simple 
procedure:  If  any  urine  can  escape  past  the  foreign  body, 
the  outer  orifice  is  closed  with  the  fingers  and  the  patient 
is  instructed  to  urinate  as  much  as  he  can,  forcing  the  urine 
into  the  urethra  until  it  is  greatly  distended.  The  orifice 
is  then  abruptly  released  and  the  escaping  fluid  sweeps  out 
the  foreign  body  with  it.  If  no  urine  can  pass  the  foreign 
body,  he  applies  a  constricting  band  above  it  and  then 
injects  water  into  the  urethra  to  distend  it  from  below, 
compressing  the  orifice  and  allowing  the  fluid  to  escape 
suddenly  when  the  urethra  has  been  sufficiently  distended 
by  the  water. 


330  SURGICAL  THERAPEUTICS 

Hemorrhage  from  Urethra. — Hemorrhage  from  the 
urethra  may  come  from  an  acute  trauma  or  from  the 
surface  of  an  ulceration.  When  the  hemorrhage  occurs  in 
association  with  an  erection  the  condition  is  sometimes 
called  stymatosis.  When  the  bleeding  point  is  in  the 
anterior  urethra  an  injection  of  adrenalin  solution  may 
arrest  it,  especially  if  an  ice-bag  be  applied  to  the  penis 
to  reduce  congestion.  In  bad  cases  a  large  sound  may  be 
introduced  and  the  organ  bandaged  very  tightly,  thus  con- 
trolling the  bleeding  by  pressure.  When  the  blood  comes 
from  the  deep  urethra,  if  injections  fail  and  the  loss  of  blood 
is  serious,  an  external  urethrotomy  may  have  to  be  made 
to  tie  the  injured  vessel  or  to  control  by  packing. 

Inflammation  of  Urethra. — Urethritis  is  almost 
invariably  gonorrheal  in  character  unless  directly  traceable 
to  a  recent  trauma.  Examination  of  the  discharge,  in  case 
of  dispute  or  of  doubt,  will  instantly  determine  the  character 
of  the  discharge:  Neisser's  coccus  does  not  occur  in  simple 
urethritis.  If  found  to  be  a  pure  staphylococcus  infection 
the  treatment  will  consist  in  simply  keeping  the  canal  clean 
by  injections  of  saturated  solution  of  boric  acid  or  the 
application  of  iodoform  powder  through  an  endoscope. 
Persistent  cases  may  require  an  application  or  two  of  a 
solution  of  silver  nitrate  by  an  Ultzmann  or  Guion  syringe. 

Tuberculosis  of  Urethra. — It  is  doubtful  if  primary 
tuberculosis  of  the  anterior  urethra  ever  occurs,  though 
numerous  cases  of  secondary  involvement  have  been  re- 
corded, and  infection  from  the  mouth  of  the  rabbi  may 
follow  ritual  circumcision.  It  presents  but  few  points  for 
clinical  observation:  pain  on  urination,  hemorrhage  from 
the  urethra,  strictures  without  preceding  gonorrhea  or 
trauma,  seropurulent  discharge,  which  may  for  a  long  time 
contain  no  tubercle  bacilli,  or  may  contain  them.  But  the 
posterior  urethra  affords  a  most  excellent  field  for  the  de- 
velopment of  local  tuberculosis,  the  prostatic  portion  being 


VARICOSE  VEINS  331 

especially  prone  to  implication.  The  most  common  form 
is  a  simple  mass  of  granulation-tissue,  but  in  bad  cases 
ulceration  and  abscesses  may  form,  with  cheesy  cavities  here 
and  there,  associated  almost  invariably  with  secondary 
tuberculosis  of  the  prostate.  In  some  cases  mere  destruc- 
tion of  granulations  by  passage  of  sounds,  followed  by  instal- 
lations of  lo-percent  iodoform  emulsion  daily  will  effect 
a  cure.  In  others  external  urethrotomy  is  necessary,  with 
curettage  of  the  diseased  areas  under  the  guidance  of  the 
eye.  In  the  worst  cases,  associated  with  tuberculosis  of 
the  prostate,  a  prostatectomy  is  the  only  means  of  cure. 
Most  careful  attention  must  be  directed  to  the  building  up 
of  the  general  health,  both  before  and  after  operative 
measures. 

URINE:    IRRITATION  FROM 

After  operations  upon  the  bladder  when  it  is  necessary 
to  leave  the  vesical  wound  open,  there  is  always  great  irri- 
tation of  the  skin  from  the  dribbling  urine,  continuing 
several  weeks.  The  temptation  is  to  prescribe  some  drying 
powder  like  borated  talcum,  oxide  of  zinc  or  carbonate  of 
calcium — all  of  which  have  been  so  long  used  in  intertrigo; 
but  if  a  dusting  powder  be  used  it  will  cake,  adhere  to 
the  skin  and  crack,  itself  becoming  a  source  of  local  irrita- 
tion and  an  annoyance  to  the  patient.  Better  is  some 
greasy  application,  e.  g.,  carbolized  vaseline;  frequent 
washing  with  a  mild  soap  and  warm  water  followed  by  an 
ointment  of  boric  acid  and  vaseline  gives  the  best  results. 

VARICOSE  VEINS 

These  are  best  treated  by  ligation  and  excision;  or  if 
very  bad,  on  the  leg,  by  the  Schede  operation  or  removal 
of  the  long  saphenous.  If  the  patient  refuse  operative  treat- 
ment the  part  may  be  bandaged  regularly  to  give  comfort 
and  support  the  weakened  vessels.  In  bad  cases  a  Martin 
bandage  (rubber)  or  silk  elastic  stocking  may  be  needed.. 


332  SURGICAL  THERAPEUTICS 

As  regards  hygiene  Robin  says:  The  most  effective 
agent  to  stimulate  the  flow  of  blood  in  the  veins  is  muscular 
action,  so  the  patient  should  be  made  to  exercise  as  much  as 
possible,  stopping  if  there  is  any  pain.  When  not  in  motion, 
he  should  not  stand.  Internally,  remedies  should  be  given  to 
stimulate  the  walls  of  the  veins,  as  tincture  of  hamamelis, 
tincture  of  viburnum  prunifolium,  tincture  of  centaurea,  aa. 
part.  aeq. ;  dose,  six  drops  each  morning.  Potassium  iodide 
will  prevent  the  sclerotic  changes  in  the  walls  of  the  veins, 
and  should  be  given  in  doses  of  about  a  grain  twice  a  day. 
Locally,  the  limb  should  be  wrapped  every  night  in  cloths 
wet  with  Goulard's  lotion,  or  in  case  this  is  refused,  spread 
thinly  with  the  following  ointment:  Potassium  iodide, 
dr.  i;  ergotin,  grs.  45;  ext.  nux  vomica,  grs.  15;  benzoinated 
lard,  oz.  i.  For  the  poorer  classes  the  bandage  of  Velpeau 
is  better  than  an  elastic  stocking.  If  a  stocking  is  used  it 
must  rise  well  above  the  knee.  Massage  is  advantageous 
and  is  most  effective  after  a  bath;  all  hard  or  tender  points 
must  be  avoided  in  this  rubbing,  lest  thrombosis  and  embo- 
lism occur. 

A  strong  solution  of  potassium  permanganate — one  to 
five  percent — forms  one  of  the  very  best  applications  for 
varicose  ulcers  of  the  leg,  whether  recent  or  of  old  standing. 
Apply  on  a  cloth  (absorbent  lint  is  the  best) ;  cloths  should 
be  saturated  every  two  to  six  hours,  and  the  same  cloth 
can  be  used  for  several  days. 

An  ointment  of  one  part  silver  nitrate,  two  parts  balsam 
of  Peru  and  97  parts  petrolatum  is  not  strictly  compatible, 
but  it  forms  a  splendid  ointment  for  varicose  ulcers. 

VARICOCELE:    CURE  OF 

When  operating  for  varicocele  it  is  far  better  to  make 
the  incision  over  the  external  ring,  as  in  herniotomy,  than 
the  usual  incision  in  the  scrotum.  The  cord,  veins  and 
artery  may  be  pushed  out  of  the  opening  and  the  veins 


VOMER:  FRACTURE  OF  333 

separated  from  the  others  and  ligated.  The  operation  is 
much  simpler  and  easier,  involves  less  laceration  and  hem- 
orrhage, and  the  danger  of  embolism,  thrombosis  and 
septic  infection  is  greatly  minimized.  It  is  wholly  unneces- 
sary to  touch  either  the  wounds  in  skin  and  tunica  vagi- 
nalis  or  the  cord  and  veins — finger-infection  here  being  very 
serious,  since  the  wound  must  be  closed  without  drainage. 
It  is  best  sealed  with  collodion,  over  which  a  protective 
gauze-pad  should  be  placed. 

VESICULITIS 

Inflammation  of  the  seminal  vesicles  is  generally  due 
to  gonorrhea.  It  may  result  in  stricture  of  the  ejaculatory 
ducts,  and  be  followed  by  abscess,  atrophy,  and  degenera- 
tion of  the  seminal  vesicles.  Ulcers,  venereal  or  otherwise, 
forming  at  the  mouths  of  these  ducts  and  finally  healing, 
may  by  the  formation  of  cicatricial  tissue  so  nearly  close 
the  lumen  of  the  ducts  as  to  prevent  the  free  escape  of  the 
fluid  into  the  urethra.  Treatment  is  symptomatic  and  non- 
surgical  except  when  abscess  forms,  this  demanding  inci- 
sion and  drainage  in  bad  cases. 

VOLVULUS 

This  is  a  form  of  obstruction  of  the  bowel  dependent 
upon  twisting  of  the  gut  upon  itself  or  upon  its  mesenteric 
axis  in  such  a  way  as  to  occlude  the  lumen.  It  is  found  most 
often  in  the  sigmoid,  hence  in  operating  for  intestinal  ob- 
struction the  hand  invariably  should  be  first  passed  to  the 
sigmoid  to  see  that  volvulus  is  not  present  there.  In  early 
operation  lies  the  only  hope  of  cure. 

VOMER:    FRACTURE  OF 

Chloroform  patient  and,  if  adult,  pass  little  finger  through 
one  nostril  and  plug  opposite  tightly  with  iodoform  gauze 
up  to  and  beside  fracture;  withdraw  finger  and  pack  oppo- 


334  SURGICAL  THERAPEUTICS 

site  side.  In  three  days  withdraw  packing  and  wash  out 
two  or  three  times  daily  with  spray  of  thymol  solution. 
In  children,  hemostatic  forceps  may  be  used  instead  of 
finger  to  push  displaced  fragments  into  proper  position. 

Great  care  should  be  taken  to  get  the  nasal  septum 
into  exactly  the  mid-line,  as  there  may  be  serious  trouble 
later  on  if  this  is  not  done.  Besides,  if  fracture  of  the 
vomer  is  not  properly  set,  deformity  may  follow. 

WARTS 

Removal  of. — For  the  removal  of  warts  as  well  as 
corns  salicylic  acid  is  extremely  efficacious.  It  is  best  used 
in  the  following  form: 

Salicylic  acid    5 

Extract  of  cannabis  indica i 

Collodion 60 

This  is  to  be  painted  on  the  wart  or  corn  at  bedtime, 
with  a  camelshair  brush.  In  four  or  five  days  the  growth 
may  be  readily  peeled  off  with  a  knife,  leaving  a  tender 
but  entirely  healthy  skin  at  its  site.  .  Or,  excision  may  be 
done,  closing  cut  with  collodion. 

WICKERSHEMER'S  FLUID 

For   the   preservation    of   specimens   Wickersheimer's 
fluid  is  much  used,  a  strong  solution  for  injecting  large 
masses,  a  weak  one  for  immersion. 
Stronger  Solution: 

Arsenous  acid 16 

Sodium  chloride 80 

Potassium  sulphate    200 

Potassium  carbonate   20 

Potassium  nitrate 25 

Glycerin 4000 

Wood-alcohol   750 

Water 10,000 


WOUNDS  335 

Weaker  Solution: 

Arsenous  acid 12 

Sodium  chloride 60 

Potassium  sulphate    150 

Potassium  carbonate  15 

Potassium  nitrate 18 

Glycerin 4000 

Wood-alcohol   750 

Water    10,000 

After  injection  with  the  stronger  solution  the  specimen 
is  to  be  put  in  the  weaker  and  the  jar  closed  tightly  to  pre- 
vent evaporation. 

WOUNDS 

Balsam  of  Peru  for  "Wounds. — Balsam  of  Peru  is 
a  much-neglected  agent  in  the  treatment  of  wounded  sur- 
faces, especially  those  attended  by  suppuration  and  conse- 
quently slow  granulation,  as  operation  for  fistula  in  ano. 
Experience  has  shown  that  the  balsam  has  certain  properties 
which  surpass  those  of  any  other  substance  at  our  disposal 
for  the  treatment  of  certain  wounds,  especially  in  crushed 
and  soiled  tissues.  Severe  inflammation  never  develops 
in  an  infected  wound  (like  that  of  a  crush  in  railway  work) 
which  has  been  treated  with  the  balsam  in  the  first  twenty- 
four  hours.  It  is  poured  freely  into  the  wound  and  every 
crevice  is  filled.  It  attracts  the  leucocytes  to  the  spot  and 
has  a  kind  of  mummifying  effect  on  the  dead  tissues,  while 
it  mechanically  checks  the  development  of  microorganisms. 

Dry  Heat  Applied  to  Wounds. — If  after  gauze, 
cotton  and  bandage  have  been  applied  over  a  wound, 
especially  an  infected  one,  the  wound  is  subjected  to  a 
high  degree  of  dry  heat  for  some  time,  healing  will  be  greatly 
hastened.  If  the  sun  is  shining  very  hot,  the  wounded 
extremity  or  part  may  be  placed  so  that  the  sunshine  burns 
it  until  every  trace  of  moisture  is  gone;  or  it  may  be 


336  SURGICAL  THERAPEUTICS 

placed  very  near  to  a  hot  stove  or  furnace  for  some  time 
— even  the  heat  of  a  Bunsen  burner  does  good  but  takes 
longer.  In  adopting  this  mode  of  treatment  no  special 
pains  need  be  taken  to  clean  the  burned  or  injured  surface ; 
it  should  not  be  washed  with  antiseptic  solutions  but  simply 
cleaned  with  dry  gauze  as  well  as  possible,  the  surrounding 
surface  being  also  cleaned  without  water.  Dry  bichloride 
gauze  (iodoform  is  better  for  this  purpose)  is  applied  in 
several  layers — which  of  course  become  instantly  moist- 
ened by  the  blood  or  serum — and  a  thin  layer  of  cotton 
placed  over  this,  with  bandage  over  all.  The  dry  heat 
is  then  applied — a  "hot-air  apparatus"  will  not  do,  as  the 
sweating  interferes  with  the  desired  desiccation — and  the 
patient  told  to  return  in  three  or  four  days.  Healing  is  by 
"third  intention"  of  the  old  writers:  healing  under  a  scab 
artificially  produced.  In  some  cases  suppuration  is  prac- 
tically prevented. 

For  Contused  Wounds. — The  old  treatment  of  rub- 
bing severe  contusions  with  tincture  of  arnica,  etc.,  has 
been  superseded  by,  first,  a  hot  bath  with  free  use  of  soap 
— the  affected  part  being  gently  but  persistently  rubbed 
with  soft  soap — then  with  tincture  of  green  soap  (an  alcoholic 
solution  of  common  soap  will  do),  and  then  careful  drying; 
and,  second,  the  application  of  dry  antiseptic  gauze  held  in 
place  by  a  bandage  not  too  tightly  applied.  Next  day 
the  soap-bathing  may  be  repeated,  and  if  there  be  suspi- 
cion of  infection  an  ointment  may  be  used,  such  as 

.     Silver  nitrate 0.3  (grs.  4  ) 

Balsam  of  Peru 6.0  (drs.  i£) 

Vaseline 90.0  (ozs.  3  ) 

This  is  rubbed  thoroughly  into  the  skin  and  the  anti- 
septic protective  applied  as  before.  After  three  or  four 
days  the  infective  process  will  be  either  under  control  or 
so  far  advanced  as  to  require  one  or  more  incisions.  These, 
if  needed  at  all,  should  be  free  ones. 


WOUNDS  337 

Suturing  Wounds. — The  skilful  surgeon  knows  how 
to  sew  the  skin  without  the  use  of  needle-forceps  and  still 
without  handling  the  cut  edges  with  his  fingers.  By  press- 
ing the  edges  together  the  needle  may  be  pushed  through 
without  any  contamination  of  raw  surfaces.  Professor 
Mikulicz,  the  distinguished  German  surgeon  (just  dead), 
remarked:  "Whoever  has  an  opportunity  of  watching  a 
surgeon  operate  can  generally  judge  at  first  glance  from 
his  manner  of  suturing,  the  degree  of  perfection  which 
his  technic  has  attained."  For  it  is  here  that  the  dex- 
terity of  the  surgeon  most  distinctly  manifests  itself.  In 
spite  of  the  numerous  ingenious  devices  for  facilitating 
the  insertion  of  sutures,  none  of  them  surpasses  the  hand. 
The  surgeon  who  has  learned  to  apply  stitches  accurately 
and  rapidly  will  often  be  able  to  shorten  materially  the 
period  of  operation,  and  thereby  greatly  diminish  the 
risk  of  shock,  and  especially  is  this  necessary  in  operative 
work  upon  the  gastrointestinal  tract;  by  the  time  the 
intraabdominal  work  is  completed  the  patient  is  often  so 
near  collapse  that  a  life  may  be  saved  by  the  knowledge 
of  how  to  suture  rapidly.  Mikulicz  has  well  pointed  out 
that  in  the  development  of  the  purely  scientific  part  of 
surgery  there  is  danger  of  forgetting  what  might  be  termed 
the  mechanics  of  the  art. 

Treatment  of  Aseptic  Wounds. — It  is  very  hard 
to  induce  the  average  doctor  not  to  "meddle"  with  a  clean 
wound.  Unless  he  has  had  practical  hospital  training  and 
has  learned  to  say  "no"  positively  and  firmly  he  cannot 
resist  his  curiosity  to  see  how  healing  is  progressing  on  the 
demand  of  the  patient  that  the  wound  be  dressed.  It  is 
extremely  difficult  to  make  the  average  patient  understand 
(and  many  a  doctor,  too)  that  an  aseptic  wound  should 
never  be  exposed  until  the  tenth  to  twelfth  day,  when  the 
stitches  are  to  be  removed;  then,  if  no  infection  be  found, 
that  it  should  not  again  be  touched  for  another  ten  days. 


338  SURGICAL  THERAPEUTICS 

When  drainage  has  been  used,  however,  unless  it  be  of 
catgut,  the  dressings  must  be  changed  in  about  forty-eight 
hours  (the  outside  cotton  and  gauze  much  sooner,  and 
often  if  there  be  much  seepage) ;  and  here  lies  a  great  dan- 
ger. For  if  the  greatest  care  be  not  exercised  infection  is 
sure  to  occur,  and  an  infection  at  first  dressing  is  just  as 
bad  as  a  dirty  operation.  Therefore,  when  an  early  dress- 
ing is  imperative  to  remove  a  gauze,  tube  or  silkworm- 
gut  drain,  it  is  necessary  (a)  that  the  hands  be  scrubbed 
and  sterilized  as  for  an  abdominal  section,  or,  better,  sterile 
rubber  gloves  be  put  on ;  (b)  that  the  gauze  be  freshly  boiled, 
or  just  out  of  a  sterilizer  without  having  been  handled; 
(c)  that  some  one  besides  the  doctor  remove  the  outside 
dressings,  down  to  the  gauze,  so  that  the  doctor's  hands  or 
gloves  shall  not  be  contaminated;  (d)  that  as  small  a  por- 
tion of  the  wound  be  exposed  as  possible  during  removal 
of  the  drain,  and  then  the  whole  wound  be  quickly  covered 
by  the  sterile  gauze  at  hand,  and  (e)  that  greatest  care  be 
taken  that  nothing  touch  the  surface  near  the  wound. 
Attempts  at  "irrigating"  or  "washing"  are  especially  to 
be  condemned;  it  is  far  better  to  leave  a  little  blood  or 
serum  on  the  wound  or  skin  than  to  make  any  great  effort 
to  clean  them  away. 

If  sutures  are  to  be  tied  and  cut  after  removal  of  the 
drain  the  scissors  must  be  taken  directly  from  the  pan  in 
which  they  have  just  been  boiled.  It  is  well,  also,  to  have 
a  pair  of  hemostats  boiled  in  the  same  pan  to  be  used  in 
pulling  out  the  drain,  catching  any  bleeding  point,  etc. 
The  patient's  hands  should  be  held  so  that  there  is  no 
possibility  of  an  involuntary  movement  contaminating  the 
wound  or  the  doctor's  hands;  and  when  possible,  sterilized 
towels  should  be  placed  over  the  bed  and  patient's  clothing 
before  the  deeper  layers  of  gauze  are  removed,  in  order  to 
insure  absolute  sterility  of  the  wound. 


WOUNDS  339 

At  the  time  for  removal  of  stitches  there  may  be  one 
or  two  little  stitch-abscesses — a  drop  of  pus  around  the 
stitch  from  the  mild  infection  of  the  staphylococcus  epider- 
midis  albus,  all  the  rest  of  the  cut  being  healed.  Such 
being  the  case  all  the  other  stitches  are  to  be  cut  and 
removed  before  the  infected  one — otherwise  the  scissors 
will  carry  the  infection  to  the  other  sutures  and  multiple 
abscesses  follow.  Besides,  such  a  wound  should  not  be 
washed  with  hydrogen  peroxide  or  other  antiseptic,  as  the 
fluid  will  carry  the  pus  to  the  other  stitch  holes.  The  best 
way  is  to  take  a  small  bit  of  absorbent  cotton  on  the  end 
of  a  wooden  tooth-pick  (or  a  probe — a  detestable  instrument 
by  the  way)  and  carefully  remove  the  pus  on  the  surface. 
If  there  seems  to  be  a  drop  or  two  deeper  down  around 
the  suture  the  wound  may  be  gently  squeezed  from  side  to 
side  and  the  pus  wiped  away.  A  little  boric  acid  sprinkled 
on  the  surface  and  a  little  plain  gauze  dressing  for  a  few 
days  will  be  all  that  is  required  generally;  but  it  is  well 
to  make  the  second  dressing  in  four  or  five  days  instead  of 
ten,  as  in  a  .perfectly  healed  wound. 

Occasionally  there  will  be  found  more  than  a  little  pus 
around  the  stitches,  three  or  four  being  infected  and  the 
surrounding  skin  a  little  reddened  and  tender.  Here  is 
a  mild  staphylococcus  infection  of  the  wound  and  it  may 
be  serious  even,  though  mild.  It  seems  to  be  purely  super- 
ficial and  all  that  is  needed  is  to  remove  the  stitches,  clean 
the  surface  as  thoroughly  as  possible,  and  apply  bichloride 
gauze  i  :  2000.  In  two  or  three  days  the  dressings  should 
be  removed,  and  if  the  trouble  be  no  better  the  treatment 
appropriate  for  infected  wounds  in  general  must  be  adopted. 

Treatment  of  Infected  Wounds. — Every  wound 
received  accidentally  is  an  infected  one.  Wounds 
inflicted  by  a  surgeon  -should,  theoretically,  be  aseptic, 
free  from  infection;  but  unfortunately  many  are  not  so 
because  of  (i)  dirty  fingers,  (2)  unclean  instruments, 


340  SURGICAL  THERAPEUTICS 

(3)  non-sterile  gauze,  (4)  failure  to  drain  when  (a)  the 
patient  is  very  fat,  (b)  there  is  much  oozing,  (c)  dead 
spaces  have  been  left  by  unskilful  suturing  or  (d)  the 
skin  was  not  properly  prepared,  so  that  stitch-abscesses 
have  formed  with  subsequent  general  infection  of  the 
wound. 

The  first  principle  of  treatment  of  an  infected  wound 
is  free  drainage.  Therefore  contaminated  wounds  should 
not  be  closely  sutured,  save  in  the  scalp  where  the  exces- 
sive vascularity  permits  healing  to  occur  more  speedily 
than  elsewhere.  If  closed  without  drainage,  extensive 
suppuration  is  almost  certain  to  occur — often  with  dis- 
astrous results:  erysipelas,  septicemia,  lockjaw. 

i.  Simple  Incised  Wounds. — No  amount  of  scrub- 
bing, irrigation  or  application  of  antiseptic  agents  can 
transform  an  infected  wound  into  a  sterile  one,  which 
may  be  closed  completely.  Nevertheless  efforts  at  attain- 
ing "near  asepsis"  should  be  made,  varying  according 
to  the  character  and  location.  When  the  wound  is  a  clean 
cut,  as  from  a  razor,  sharp  knife,  sickle  or  other  weapon 
that  is  not  presumed  to  be  swarming  with  bacteria, 
though  not  surgically  clean,  the  proper  treatment  is  to 
scrub  the  surrounding  surfaces  and  the  edges  of  the  incis- 
ion with  soap  and  water,  then  wash  with  alcohol  for  a 
half  minute  and  finally  apply  gauze  saturated  with  solu- 
tion of  bichloride  of  mercury,  i  :  2000,  or  phenol,  i  :4o; 
finally  flushing  the  wound  itself  with  the  sublimate  or 
phenol  solution. 

In  the  absence  of  these  agents  oil  of  turpentine  makes 
a  fairly  good  antiseptic  agent. 

A  wound  thus  prepared  is  in  fairly  good  shape  for 
closure.  Very  small  wounds  may  be  closed  without 
drainage,  as  may  also  practically  all  cuts  about  the  scalp 
and  face.  But  in  every  other  part  of  the  body  some  kind 
of  drain  must  be  inserted.  In  many  instances,  if  hemor- 


WOUNDS  341 

rhage  is  completely  :ontrolled,  two  or  three  strands  of 
catgut  may  be  pushed  to  the  depths  of  the  wound  at  one 
or  two  places  (according  to  size  of  cut)  and  left  projecting 
through  the  skin;  if  there  be  much  oozing  or  the  cut  be 
deep  it  is  better  to  put  in  a  little  strip  of  gauze  in  one  or 
two  places. 

For  this  partial  closure  of  an  infected  wound  silk- 
worm gut  is  the  ideal  suture,  except  for  wounds  of  the 
face  and  scalp,  where  lo-day  chromicized  catgut  No.  i  is 
to  be  preferred. 

When  the  wound  has  thus  been  cleaned,  closed  and 
drained,  it  should  be  covered  by  several  layers  of  gauze, 
preferably  wrung  out  of  the  sublimate  or  phenol  solution; 
a  pad  of  absorbent  cotton  applied;  and  a  bandage  so 
placed  as  not  to  press  tightly  upon  the  wound,  as  this 
would  interfere  with  the  free  drainage  desired. 

The  closure  of  such  wounds  by  collodion  cannot  be 
too  strongly  condemned.  The  application  of  dusting 
powders,  like  iodoform,  bismuth,  etc.,  is  also  highly  objec- 
tionable. Such  wounds  should  be  dressed  on  the  third 
or  fourth  day.  The  gauze  removed,  the  wound-surface 
is  first  carefully  inspected,  and  if  found  free  from  inflam- 
mation or  much  discharge,  the  drains  are  withdrawn  by 
sterile  forceps  and  the  surfaces  quickly  covered  with 
gauze,  without  handling  or  washing.  If  there  be  much 
discharge  the  surface  must  be  cleaned  by  gently  wiping 
with  clean  gauze  or  cotton  and  the  antiseptic  dressing 
applied.  If  inflammation  of  a  severe  degree  be  deemed 
impending  some  of  the  sutures  may  be  cut  and  the  wound 
permitted  to  gape.  In  some  cases  the  wound  should  be 
inspected  again  in  forty-eight  hours. 

Badly  Lacerated  Wounds. — The  method  of  cleaning 
a  badly  lacerated  wound  is  the  same  as  that  of  the  simple 
wound  except  as  to  the  management  of  the  wounded 
surfaces  themselves. 


342  SURGICAL  THERAPEUTICS 

If  there  be  grease  and  much  dirt  in  the  wound  it  is  a 
good  plan  to  clean  it  out  with  gasolin,  followed  by  65- 
percent  alcohol  and  then  i  :  2000  sublimate  solution.  All 
scraps  of  injured  skin,  muscle,  etc.,  which  are  so  injured 
as  to  be  certain  to  die  must  be  trimmed  away  with  scis- 
sors— leaving  them  only  makes  infection  worse  and  delays 
healing  many  days. 

It  is  in  these  deep,  lacerated  wounds  that  antiseptics 
like  iodoform  do  good.  A  very  useful  preparation  is 

Camphor    39  parts 

Phenol 21  parts 

Liquid  petrolatum 40  parts 

This  may  be  poured  into  the  wound  freely,  the  excess 
being  permitted  to  run  into  the  gauze,  which  is  applied 
over  the  hole.  It  is  especially  valuable  in  wounds  involv- 
ing joints. 

Or  if  the  bone  be  injured  it  is  usually  better  to  fill  the 
depths  with  iodoform  and  cover  with  lo-percent  iodo- 
form gauze. 

Sometimes  the  wound  may  be  partly  closed  by  stitches 
— patients  prefer  to  have  it  so.  But  often  it  is  best  just 
to  pack  the  cavity  loosely  with  sterile  gauze. 

This  kind  of  wound  should  be  dressed  in  forty-eight 
hours,  or  sooner  if  the  gauze  and  cotton  become  saturated 
with  serum  and  pus  or  if  high  fever  develop.  At  the  first 
dressing  it  is  best  not  to  disturb  the  depths  unless  there 
be  fragments  of  tissue  to  remove  or  necessity  for  provid- 
ing freer  drainage. 

At  the  second  or  third  dressing  wound-secretion  will 
be  abundant.  If  putrefaction  is  going  on  there  will  be 
a  disagreeable  "stinking"  odor,  and  it  may  be  neces- 
sary to  trim  out  dying  tissue  and  pour  in  a  considerable 
quantity  of  liquid  phenol  (95-percent  carbolic  acid),  almost 
instantly  neutralizing  it  by  pouring  in  pure  alcohol.  Then 
the  dressings  are  applied  as  before. 


WOUNDS  343 

After  a  few  days  the  amount  of  discharge  may  be 
very  great,  from  a  large  wound,  so  great  that  the  surgeon 
desires  to  lessen  it.  For  this  purpose  may  be  used 

Resorcin    • i  part 

Boric  acid —  20  parts 

Apply  freely  to  all  parts  of  the  infected  surfaces  and  cover 
with  gauze  and  cotton. 

The  practice  of  covering  the  dressings  of  these  wounds 
with  rubber  tissue  or  oiled  silk  cannot  be  too  severely 
criticized:  such  "protective"  simply  adds  to  the  capacity 
of  the  bacteria  to  multiply. 

In  some  cases,  when  granulation  seems  to  be  delayed 
too  long,  it  is  good  practice  to  cover  the  wounded  sur- 
faces with  a  few  layers  of  bichloride  gauze  held  in  place 
by  strips  of  adhesive  plaster  around  the  edges  and  place 
the  patient  where  the  wind  may  blow  over  the  sore;  or  in 
winter  to  place  the  patient  near  a  fire  so  that  by  evapora- 
tion of  the  watery  part  of  the  discharge  the  process  of 
nature's  "healing  under  a  scab"  may  be  simulated. 

After  granulation  has  been  well  begun  the  less  the 
surface  is  disturbed  the  better.  Dressings  should  be 
changed  only  when  becoming  foul;  and  the  discharges 
must  be  merely  mopped  away  in  the  gentlest  manner 
possible — all  water,  hydrogen  dioxide,  sublimate  solu- 
tion, etc.,  should  be  banished,  save  for  cleaning  the  skin 
contiguous  to  the  wound;  and  as  a  rule  the  less  that  is 
disturbed,  also,  the  better.  Plenty  of  clean  gauze  and 
cotton,  with  a  loose  bandage,  and  perfect  quietude,  will 
now  do  more  than  all  the  antiseptics  made.  It  is  hard 
to  make  the  average  nurse  leave  such  wounds  alone — 
she  invariably  wants  to  "do  something,"  and  not  seldom 
the  patient  and  the  doctor  also.  "Blessed  is  he  who 
has  learned  to  do  nothing  well." 

(3)  Punctured  Wounds. — Punctured  wounds  are 
extremely  dangerous,  since  they  are  always  infected  and 


344  SURGICAL  THERAPEUTICS 

do  not  by  their  nature  permit  drainage  without  enlarge- 
ment by  the  surgeon.  Penetrating  wounds  of  the  abdo- 
men are  particularly  serious,  and  the  invariable  rule 
should  be  to  enlarge  and  explore  them  or  to  make  a  median 
section  if  viscera  are  known  to  be  injured. 

Every  penetrating  wound  of  any  great  magnitude 
should  be  treated  by  thorough  cleaning  of  the  adjacent 
skin  and  wide  incision  to  the  bottom  of  the  original  injury, 
however  deep  it  may  be.  Then,  unless  some  internal 
organ  or  delicate  tissue  prohibit,  the  surface  may  be 
cauterized  with  pure  phenol,  followed  in  half  a  minute 
by  pure  alcohol.  Before  this  is  done,  however,  careful 
search  should  be  made  for  foreign  bodies  if  the  nature 
of  the  accident  is  such  that  particles  of  clothing,  dirt, 
splinters,  etc.,  may  have  been  carried  into  the  depths, 
and  the  incision  partially  closed  by  sutures  so  introduced 
as  not  to  interfere  with  free  drainage. 

The  only  exception  to  this  rule  of  treatment  is  in  gun- 
shot wounds  of  the  lung;  and  rarely  in  shot-wounds  of 
the  brain. 

(4)  Badly  Contused  Wounds. — When  large  surfaces 
have  been  badly  bruised  without  apparent  destruction 
of  the  deep  structures  the  best  management  is  to  clean 
the  skin  with  65-percent  alcohol  (the  virtues  of  the  "old- 
fashioned"  tincture  of  arnica  are  ascribable  to  the  effect 
of  its  alcohol)  and  then  cover  with  several  layers  of  gauze, 
either  dry  or  saturated  with  the  mixture  of  camphor  and 
phenol  above  mentioned. 

When  there  is  much  pain  from  the  bruising  another 
phenol  combination  may  be  employed,  and  which  has  the 
following  composition : 

Chloral   hydrate i  part 

Phenol i  part 

Mix  in  a  mortar  sterilized  by  boiling  and  keep  in  a 
bottle  similarly  cleaned.  Gauze  or  clean  flannel  may 


WOUNDS  345 

be  saturated  with  this  and  applied  to  the  sore.  It  is 
both  antiseptic  and  anodyne. 

Such  a  wound  ought  to  be  redressed  in  forty-eight 
hours  in  order  to  see  that  the  deeper  tissues  are  not  slough- 
ing. As  soon  as  it  is  apparent  that  sloughing  is  sure  to 
occur  it  is  best  to  open  the  wound  freely,  in  several  places 
if  necessary,  to  permit  early  and  free  drainage.  By  this 
measure  one  may  often  prevent  a  deep  slough  and  a  long, 
tedious  period  of  suppuration. 

If  in  spite  of  the  most  careful  antiseptic  treatment 
constitutional  symptoms  arise  the  treatment  for  the  par- 
ticular kind  of  sepsis  must  be  instantly  adopted,  i.  e., 
staphylococcic,  streptococcic,  saprophytic,  etc. 

Post-Operative  Complications 

Postoperative  Cystitis. — One  of  the  most  annoy- 
ing symptoms  after  operation,  requiring  frequent  catheteri- 
zation,  is  the  irritation  of  the  neck  of  the  bladder  com- 
monly called  "cystitis" — though  as  a  matter  of  fact  the 
trouble  only  rarely  becomes  a  true  inflammation  of  the 
bladder.  But  an  infection  of  the  whole  bladder  may 
occur — a  matter  of  greatest  import.  Hence  the  necessity 
of  the  greatest  care  in  catheterization. 

Prevention. — The  nurse  must  be  instructed  to  boil 
the  catheter  each  time  before  its  introduction,  and  to 
scrub  carefully  her  hands  before  taking  the  instrument 
from  the  boiler — in  doing  which  the  fingers  should  touch 
only  that  part  which  is  not  to  go  into  the  bladder.  A 
small,  smooth,  glass  tube  is  often  preferable  to  the  rectal 
or  rubber  catheter,  but  care  must  be  taken  that  it  is  not 
broken  while  in  the  urethra.  Of  importance  equal  to 
that  of  sterilization  of  instrument  and  cleansing  of  hands 
is  that  the  meatus  be  carefully  exposed  and  cleaned 
immediately  before  introduction  of  the  catheter.  If 
the  patient  will  permit,  6 5 -percent  alcohol  should  be 


346  SURGICAL  THERAPEUTICS 

used,  „  on  a  little  gauze  or  absorbent  cotton,  for  mopping 
the  urethral  orifice,  but  many  women  protest  so  strenu- 
ously, because  of  the  smarting  it  produces,  that  it  cannot 
be  employed,  in  which  case  5 -percent  carbolized  water 
must  be  substituted. 

But  sometimes,  in  spite  of  all  these  precautions,  infec- 
tion does  occur;  or  as  a  result  of  trauma,  or  of  too  long 
retention,  bladder  irritation  does  arise.  What  then 
is  to  be  done? 

For  Acute  Cases. — For  relief  of  the  intense  suffering 
opiates  sometimes  must  be  given;  the  phosphate  of  codeine 
hypodermically  in  doses  of  seven  centigrams  (one  grain) 
as  often  as  needed  being  best,  since  it  interferes  less  with 
peristalsis  and  the  secretions  than  any  other  alkaloid 
of  opium.  Rest  in  bed  during  the  acute  stage  is  abso- 
lutely imperative. 

One  of  the  most  valuable  of  all  drugs  used  for  cystitis 
is  salicylate  of  phenol  (salol).  This  consists  of  about 
65-percent  salicylic  acid  and  35-percent  phenol,  is  decom- 
posed slowly  in  the  intestine  by  the  pancreatic  fluid  into 
its  original  constituents,  and  is  eliminated  through  the 
urine  as  urate  of  salicyl,  though  if  given  in  large  quantities 
some  seems  to  pass  into  the  bladder  unchanged.  In 
5-grain  doses  every  three  hours  it  effectually  prevents 
decomposition  of  the  urine  in  the  bladder  and  keeps  it  from 
becoming  alkaline.  It  cannot  be  continued  very  long 
on  account  of  producing  phenoluria.  Whenever  the  urine 
becomes  smoky,  boric  acid  should  be  substituted  for  a 
few  days,  thus: 

Saturated  solution  of  boric  acid 192.0  (ozs.  6) 

Tincture  of  hyoscyamus 64.0  (ozs.  2) 

Directions:     One  tablespoonful  every  six  hours. 

The  patient  must  be  put  on  a  milk  (or  liquid)  diet  for 
some  days  and  directed  to  drink  as  much  water  as  pos- 
sible. 


WOUNDS  347 

Irrigation  of  the  bladder,  during  the  acute  stage, 
may  be  practised,  a  saturated  solution  of  boric  acid  being 
excellent,  or  one-half  of  one  percent  (i  :  200)  formaldehyde 
solution  may  be  tried — in  each  instance  leaving  a  little 
of  the  solution  in  the  bladder.  The  irrigation  may  be 
made  each  time  the  catheter  is  used,  if  catheterization 
is  still  continued.  As  a  rule,  however,  the  cystic  irritation 
appears  some  days  after  discontinuance  of  the  use  of  the 
catheter,  in  which  case  irrigation  should  be  ordered 
twice  daily. 

Chronic  Cystitis.— In  spite  of  the  most  energetic  treat- 
ment, however,  the  irritation  of  the  bladder  may  per- 
sist for  months. 

Probably  the  most  satisfactory  remedy  is  lithia;  it 
may  be  given  as  an  effervescent  tablet  in  a  glassful  of 
water  three  times  a  day  for  long  periods;  or  the  benzoate 
of  lithium  may  be  used  in  doses  of  one  or  two  decigrams 
(i  to  3  grains)  every  4  hours  during  the  day  until  the 
stomach  rebels. 

If  there  is  much  annoyance  from  having  to  urinate 
at  night,  2  grams  (grs.  30)  of  bromide  of  potassium  with 
a  teaspoonful  of  tincture  of  hyoscyamus  may  be  ordered 
at  bedtime. 

To  some  patients  arbutin  (from  uva  ursa)  in  doses 
of  one  centigram  (gr.  1-6)  four  to  six  times  a  day  brings 
relief.  Others  are  benefited  by  half-gram'  doses  (grs. 
7  1-2)  of  salicylate  of  phenol  four  times  a  day. 

Extreme  cases  demand  irrigation  of  the  bladder  with 
a  saturated  solution  of  boric  acid  three  times  a  week; 
after  a  few  washings  it  is  well  to  inject  a  dram  of  fluid 
extract  of  hydrastis  in  two  ounces  of  water,  at  the  end 
of  an  irrigation,  leaving  it  in  the  bladder.  As  a  rule, 
however,  the  less  local  treatment  the  better  in  the  end. 
Patience — and  two  quarts  of  water  drunk  daily — will  do 
much  toward  cure. 


348  SURGICAL  THERAPEUTICS 

For  internal  use  in  chronic  cystitis  this  formula  is 
highly  praised: 

Venice  turpentine 5.0  (grs.  75) 

Castoreum 2.0  (grs.  30) 

Camphor 4.0  (grs.  60) 

Calcined   magnesia sufficient 

Make  into  40  pills.  Directions:  Three  to  six  pills 
daily. 

Briefly  summarized,  other  treatment  is:  Remove 
any  discoverable  source  or  sources  of  irritation  which 
act  through  the  medium  of  the  urine;  also  any  mechanical 
source  of  vesical  irritation  should  receive  appropriate 
treatment. 

The  urine  should  be  rendered  bland  by  the  use  of  a 
milk  diet,  the  ingestion  of  considerable  quantities  of 
water,  the  administration  of  potassium  citrate  if  too  acid, 
or  of  boric  acid  and  phenol  salicylate  (salol)  if  alka- 
line. 

Pelvic  congestion  should  be  relieved  by  hot  vaginal 
douches,  placing  the  patient  in  the  knee-chest  position, 
and  the  correction  of  constipation. 

The  inflamed  cystic  membrane  may  be  relieved  by 
the  administration  of  santal-wood  oil,  copaiba  or  creosote 
by  mouth,  or  injections  of  boric  acid,  carbolic  acid,  or 
nitrate  of  silver  in  suitable  strengths. 

The  general  health  should  be  improved  by  tonics, 
and  so  on. 

Postoperative  Delirium. — Some  hours  after  an 
operation,  when  the  patient  ought  to  be  clear-headed, 
delirium  may  appear.  This  is  generally  of  mild  degree 
and  may  depend  upon 

1.  The  effects  of  the  anesthetic. 

2.  Mild  infection. 

3.  Prolonged  abstinence  from  food. 

4.  Absorption  of  iodoform. 


WOUNDS  349 

1.  When  postoperative  delirium  is  due  to  the  anes- 
thetic it  usually  is  present  as  soon  as  the  patient  awakens, 
though  rarely  it  is  not  noted  until  the  day  after  the  opera- 
tion.    It  is  more  liable  to  follow  ether  than  chloroform, 
and  is  not  at  all  infrequent  after  the  use  of  the  hyoscine- 
morphine  form  of  anesthesia,  especially  when  an  impure 
scopolamine  is  substituted  for  hyoscine.     It  subsides   in 
a  few  hours,  or  at  least  as  soon  as  the  bowels  have  been 
moved    freely,    and    need    not,    therefore,    occasion    any 
special  anxiety. 

2.  Delirium  arising  from  a  mild  infection,  however, 
is  a  quite  serious  matter,  if  persistent.     It  is  most  likely 
to  appear  on  the  third  or  fourth  day  after  operation,  and 
if  the  infection  be  severe  instead  of  mild,  may  be  regarded 
as  a  most  unfavorable  sign,  since  it  often  is  but  the  fore- 
runner of  the  fatal  termination  of  the  sepsis.     Upon  its 
appearance  the'  most  energetic  measures  must  be  insti- 
tuted: thorough  purgation  followed  by  sustaining  reme- 
dies, and  the   most   careful  inspection   of  the  wound  with 
active    work    to    render    the    injured    surfaces    inoccuous 
by  perfect   drainage,   cleanness   of  dressings,   etc. 

In  the  worst  cases  a  low,  muttering  delirium  replaces 
sleep  at  night;  in  which  cases  one  gram  (grs.  15)  each  of 
potassium  bromide  and  chloral  hydrate  may  be  given 
in  4  ounces  of  starch  water  by  rectum  at  bedtime.  This 
will  insure  a  good  night's  rest  and  the  patient  often  awakens 
quite  refreshed  and  clear  of  mind.  The  curative  treat- 
ment is  purely  eliminative:  purgation,  diuresis  and  dia- 
phoresis by  proper  agents,  but  above  all,  drainage.  The 
prognosis  is  always  grave. 

3.  The  delirium  of  hunger  is,  of  course,  most  likely 
to  be  present  after  operations  on  the  stomach  and  intes- 
t'nes,  when  on'y  rectal  feeding  is  possible  for  some  days, 
though  it  may  follow  an  operation  when  there  is  long- 
continued   suffering    and   prolonged   liquid   diet.     If   not 


350  SURGICAL  THERAPEUTICS 

recognized  and  corrected,  melancholia  or  even  acute 
mania  may  develop,  the  mental  equipoise  being  lost  for 
a  long  time.  Usually  the  mental  disturbance  disappears 
spontaneously  as  soon  as  solid  food  is  given  in  sufficient 
quantity  to  supply  the  good  red  blood  essential  to  clear 
cerebration.  It  is  needless,  perhaps,  to  say  that  the 
only  treatment  consists  in  stimulation  and  nourishment. 

4.  lodoform  delirium  was  quite  common  when  it  was 
the  custom  to  pack  all  septic  cavities  with  iodoform  gauze. 
Now  most  surgeons  use  this  form  of  gauze  only  to  drain 
the  pelvis  (as  after  .vaginal  hysterectomy),  to  fill  tuber- 
culous cavities,  to  drain  the  uterus  and  to  tampon  an 
appendical  abscess;  so  iodoform  delirium  is  not  so  fre- 
quently seen  as  it  was  some  years  ago.  As  soon  as  delir- 
ium is  noted  in  any  case  where  iodoform  has  been  employed 
a  change  in  the  character  of  the  dressing  must  be  promptly 
made,  and  especially  if  the  urine  show  •  elimination  of 
iodine.  The  delirium  will  commonly  subside  in  a  fe\\ 
hours  after  removal  of  the  cause;  but  in  rare  instances 
recovery  is  deferred  for  a  long  time. 

Postoperative  Erysipelas, — Erysipelas  may  appear 
in  a  wound  (i)  by  reason  of  contamination  at  time  of  injury 
— as  in  stab-wounds  of  the  belly,  (2)  by  imperfect  efforts 
at  cleaning  the  hands  of  operator  or  assistants,  and  (3) 
by  infection  during  a  change  of  dressings. 

It  is  claimed  that  transmission  of  the  pathogenic 
bacteria  from  one  part  of  the  body  to  another  through 
the  circulation  is  possible,  but  it  is  extremely  doubtful: 
very  severe  erysipelas  may  be  present  on  the  face,  yet 
a  wound  of  the  foot  heal  by  primary  union.  The  cause 
of  the  trouble  is  the  introduction  into  the  wound  of  the 
streptococcus  pyogenes. 

The  trouble  may  make  its  appearance  at  any  time 
from  the  fourth  to  the  eleventh  day.  Usually  the  patient 
seems  to  be  doing  well  until  the  fourth  or  fifth  day  (or 


WOUNDS  351 

later),  when  headache  and  general  discomfort  come  on, 
with  coated  tongue  and  loss  of  appetite;  and  the  site  of 
injury  which  up  to  this  time  has  been  free  from  any  great 
pain  suddenly  gives  a  sensation  of  tension,  smarting  and 
tenderness.  A  severe  chill  soon  follows  (or  in  extreme 
cases  may  be  the  first  symptom)  with  sudden  rise  of 
temperature  to  104°  or  io5°F.  Associated  with  this 
r'se  in  temperature  there  will  be  nausea  and  often 
vomiting,  without  other  signs  of  peritoneal  infection 
(tympanites,  etc.),  and  sometimes  also  a  mild  delirium. 

If  the  wound  be  examined  at  the  beginning  of  the 
trouble — as  after  the  chill — it  will  be  found  that  instead 
of  being  perfectly  clean  and  free  from  irritation,  as  an 
aseptic  wound  should  be,  there  is  a  beginning  crimson 
blush  along  the  wound-margins,  with  slight  swelling. 
A  little  later  there  may  be  considerable  edema  of  the  skin, 
which  often  assumes  a  purplish  hue,  and  extension  of 
the  area  of  redness,  which  is  sharply  defined  from  the 
unaffected  skin;  and  still  later  small  bullrc  may  form. 

In  the  meantime  the  general  condition  remains  bad: 
high  fever,  great  uneasiness  even  to  delirium,  diminution 
of  urine,  with  occasional  albuminuria.  If  the  wound  is 
not  promptly  opened  and  thoroughly  drained,  typical 
streptococcic  septicemia  develops  and  death  may  occur, 
from  pyemia  or  general  exhaustion. 

But  if  the  infection  is  quickly  attended  to,  the  symp- 
toms gradually  subside  and  in  from  six  to  ten  days  there 
is  a  satisfactory  decline  in  temperature,  the  tongue  cleans, 
the  appetite  returns  and  convalescence  is  assured. 

During  the  favorable  change  the  local  symptoms 
ako  improve:  the  redness  and  edema  gradually  disap- 
pear, suppuration  is  established  and  desquamation  occurs 
— the  streptococcic  infection  with  general  sepsis  has  been 
superseded  by  a  local  staphylococcus  infection,  to  be 
followed  bv  healing  bv  granulation. 


352  SURGICAL  THERAPEUTICS 

In  very  bad  cases,  when  deep  cellular  infection  has 
occurred,  there  may  be  sloughing  of  considerable  tissue, 
with  consequent  long-delayed  healing.  In  the  most 
virulent  type  large  areas  of  skin  and  deeper  tissues  become 
necrotic — usually  followed  by  death. 

In  one  case  under  my  care  the  entire  uterus,  the  vagina, 
all  of  the  bladder  excepting  a  very  small  portion  between 
the  ureters,  the  perineum,  and  the  rectum  well  up  into 
the  sigmoid,  all  sloughed  away;  yet  the  patient  is  still 
alive. 

Treatment  must  be  both  local  and  constitutional; 
and  both  must  be  energetic.  Here  the  "therapeutic 
nihilist"  loses  his  patients;  the  man  who  is  a  "doctor" 
as  well  as  "surgeon"  saves  his. 

The  first  indication  is  to  cut  the  stitches,  if  any,  clean 
tne  wound  and  loosely  pack  it  with  antiseptic  gauze  in 
such  way  as  to  secure  freest  drainage.  Probably  the 
best  local  antiseptic  is  creolin:  8  grams  to  the  liter  of  water 
(or  one  dram  to  the  pint);  the  dressings  to  be  kept  sat- 
urated with  this. 

On  the  next  day  after  discovery  of  the  infection,  if 
it  is  seen  that  the  disease  is  inclined  to  spread,  a  little 
of  a  2-percent  solution  of  cocaine  may  be  injected  into 
the  cellular  tissue  a  little  beyond  the  infected  area,  on 
four  sides;  this  to  be  followed  by  injection  of  a  2-percent 
solution  of  phenol — about  15  minims  to  be  used  in  each 
of  the  four  injection-points,  but  the  position  of  the  needle 
so  changed  that  not  more  than  5  drops  are  left  in  any 
one  place.  This  injection  may  be  repeated  next  day, 
in  larger  dosage,  if  the  erysipelatous  blush  has  extended. 

Later,  when  itching  and  burning  are  annoying,  10- 
percent  ichthyol  ointment  mixed  with  extract  of  bella- 
donna may  be  applied,  using  lanolin  as  the  vehicle.  It 
not  only  allays  irritation  but  seems  to  exert  a  salutary 
effect  on  the  course  of  the  disease. 


WOUNDS  353 

In  the  very  bad  cases,  when  there  is  deep  cellular 
inflammation  in  the  tissues  surrounding  the  wound,  it 
is  imperative  not  only  to  cut  the  stitches  and  drain  the 
wound  but  also  to  make  numerous  free  and  deep  incis- 
ions into  the  edematous  tissues;  these  permit  escape  of 
the  infected  fluids  and  allow  the  antiseptic -solutions  to 
reach  many  foci  of  infection.  Rarely  the  application 
of  a  hot  charcoal  and  phenol  poultice  or  the  use  of  the 
cataplasma  kaolini,  U.  S.  P.,  for  a  few  hours,  followed 
by  the  creolin  solution,  seems  to  be  of  advantage  in  these 
phlegmonous  cases. 

Internally  the  best  manner  of  combating  the  trouble 
it  to  give  2  decigrams  (grs.  3)  of  quinine  sulphate  with 
5  centigrams  (gr.  5-6)  of  codeine  sulphate  every  4  hours, 
in  capimle;  or  if  vomiting  is  severe,  codeine  phosphate 
may  be  given  hypodermically  with  quinine  bisulphate 
(using  4  decigrams,  or  grs.  6)  every  six  hours.  Pilocar- 
pine  nitrate  must  be  alternated  with  this,  either  by  mouth 
or  hypodermically,  until  profuse  sweating  occurs.  One 
centigram  (gr.  1-6)  may  be  given  by  mouth  every  4  hours; 
or  half  this  quantity  subcutaneously. 

After  the  first  twenty-four  hours  this  line  of  treat- 
ment is  to  be  discontinued  and  a  good  saline  laxative 
given.  After  the  bowels  have  been  moved  freely,  if  fever 
continues  high,  half  a  milligram  (gr.  1-134)  of  aconitine 
may  be  given  every  hour  until  the  pulse  becomes  soft  and 
the  temperature  drops;  and  then  one  every  4  to  6  hours 
as  indicated.  The  phosphate  of  codeine  may  be  con- 
tinued as  often  as  needed  to  keep  the  patient  comfortable. 

In  extraordinarily  severe  cases  a  few  doses  of  Mar- 
morek's  antistreptococcus  serum  may  be  injected,  though 
it  is  of  doubtful  value  as  now  prepared. 

When  delirium  is  prominent  and  sleep  disturbed 
an  enema  of  one  gram  (grs.  15)  each  of  chloral  and  potas- 
sium bromide  in  a  cupful  of  starch  water  may  be  given 


354  SURGICAL  THERAPEUTICS 

at  bedtime  and  repeated  in  one  hour  if  needed.  It  not 
only  allays  nervousness  and  promotes  sleep  but  also 
arrests  vomiting,  if  present. 

Hyoscine  hydrobromide  also  checks  the  tendency  (o 
delirium:  dose,  one  milligram  (gr.  1-67)  every  4  to  6  hours. 
If  the  patient  is  very  weak,  stimulants  are  indicated, 
used  carefully;  egg-nog,  milk-punch,  and  sherry,  with 
egg,  being  particularly  beneficial.  When  the  heart  seems 
inclined  to  fail,  strychnine  sulphate  is  indicated,  in  doses 
of  two  milligrams  (gr.  1-34)  hypodermically.  And  when 
the  urine  is  scanty  as  well  (from  weak  heart  chiefly), 
sparteine  sulphate  is  to  be.  given:  dose,  one  decigram 
(grs.  i  1-2)  every  three  or  four  hours. 

If  extreme  weakness  should  come  on,  with  tendency 
to  heart-failure,  camphorated  oil  may  be  injected — 10 
drops  every  four  to  six  hours. 

With  all  of  this,  forced  feeding  is  essential,  especially 
in  the  weak  and  debilitated.  In  many  instances  it  is 
advisable  to  use  nutrient  enemata  as  often  as  every  six 
hours  until  the  patient  has  been  carried  past  the  critical 
point. 

During  convalescence  a  tonic  treatment  is  to  be  insti- 
tuted, with  a  mild  laxative  at  bedtime. 

Postoperative  Insanity. — While  most  cases  of  post- 
operative delirium  terminate  quite  soon  either  in  death  or 
recovery,  a  few  linger  on  until  a  true  postoperative  insanity 
is  present.  And  occasionally  an  acute  mania  follows 
the  operation  very  speedily.  Sometimes,  too,  the  mental 
depression  preceding  and  following  operation  deepens 
until  the  victim  becomes  first  neurasthenic  and  then 
melancholic. 

4It  is  a  peculiar  fact  that  the  severity  of  the  operation 
has 'no  bearing  upon  the  development  of  postoperative 
insanity  (or  postoperative  neuroses),  some  of  the  worst 
cases  following  insignificant  surgical  measures. 


WOUNDS  355 

Without  doubt  most  cases  of  insanity  following  opera- 
tions occur  in  patients  predisposed  to  this  form  of  men- 
tal disorder,  who  were  upon  the  border-land  of  aliena- 
tion prior  to  operation.  But  it  is  very  hard  to  convince 
the  laity  that  the  insanity  is  not  due  to  the  operative  work 
alone.  In  this  class  of  cases  the  anesthetic  is  probably 
the  disturbing  element. 

In  most  instances,  however,  the  delirium  at  the  out- 
set of  the  trouble  is  accompanied  by  a  comparatively 
slight  rise  of  temperature,  showing  that  the  mental  dis- 
turbance is  clearly  due  to  a  mild  form  of  sepsis. 

Perhaps  the  worst  cases  are  those  in  which  the  delir- 
ium waxes  into  an  acute  mania — requiring  removal  to 
an  asylum — but  even  then  a  large  proportion  can  be 
restored  to  health. 

While  of  almost  equal  import,  melancholia  is,  fortunately, 
not  so  common.  It  is  prone  to  be  associated  with  sui- 
cidal impulses;  and  many  deaths  have  been  recorded  from 
this  cause.  Hence  at  the  very  first  appearance  of  severe 
mental  disturbance  in  the  patient  a  constant  attendant 
must  be  provided. 

The  treatment  does  not  vary  from  that  of  insanity 
from  any  other  cause:  Good  food,  free  elimination, 
perfect  tranquillity,  isolation  if  indicated,  and  judicious 
use  of  tonic  remedies  such  as  strychnine,  iron,  etc.  An 
exceedingly  useful  combination  in  these  cases  is  the 
following: 

Valerianate  of  zinc 1.5  (grs.  20) 

Valerianate  of  quinine 1.5  (grs.  20) 

Valerianate  of  iron 1.5  (grs.  20) 

Phosphate  of  codeine 0.2  (grs.    3) 

Make  into  20  capsules.     Directions:     One  capsule  one 
hour  after  each  meal,  with  a  mild  cathartic  at   bedtime. 
Chloral  hydrate  will  be  found  one  of  the  best  hypnotics 
in  most  of  these  cases. 


356  SURGICAL  THERAPEUTICS 

Postoperative  Jaundice. — Jaundice  following  opera- 
tion may  be  due  to 

1.  Trouble  with  biliary  tract. 

2.  Septic  infection.  • 

3.  Acute  yellow  atrophy  of  liver. 

4.  Jaundice  unrecognized  before  operation. 

1.  From  the  first  to  the  third  day  after  a  perfectly 
aseptic  operation  jaundice  may  appear,  especially  if  there 
has   been   much   vomiting;   a   jaundice   accompanied   by 
the  presence   of  bile   in  the  urine   and  other  symptoms 
of    cholecystitis:    "catarrhal    jaundice."     This    may    be 
due  to  the    anesthetic,  though    how  chloroform  or  ether 
may   set   up   an   acute   cholecystitis   is   not   explainable. 
Possibly  latent  trouble  in  the  gall-bladder  may  be  aroused 
by  the  vomiting  from  the  anesthetic  into  making  itself 
recognizable;  or  it  may  be  the  trouble  is  due  to  simple 
biliary  retention  by  reflex  irritation. 

This  variety  of  jaundice  is  of  benign  character,  dis- 
appearing in  a  few  days — in  from  six  to  ten  days — after 
free  bowel-movements  have  been  secured. 

The  best  treatment  is  a  half  centigram  (gr.  1-6)  of 
calomel  every  half  hour  until  10  or  12  doses  are  taken; 
followed  by  a  bottle  of  citrate  of  magnesia  or  a  good  dose 
of  other  saline  laxative.  Then  a  few  days  on  sodium 
phosphate,  t.  i.  d.,  and  a  light  diet  will  complete  the  cure. 
But  the  patients  who  suffer  from  postoperative  "catar- 
rhal" jaundice  should  be  told  that  there  may  be  trouble 
in  later  years  from  a  gallstone,  unsuspected  before  the 
operation,  which  was  the  cause  of  this  attack  of  jaun- 
dice by  being  temporarily  driven  into  the  gall-duct  by 
efforts  at  vomiting. 

2.  More  often,  however,  the  yellowness  of  the  skin  is 
dependent  upon  septic  infection.     This  darkening  of  the 
skin,  however,  does  not  appear  later  than  it  does  in  the 
simple,  catarrhal  form,  commonly  not  until  the  sixth  to 


WOUNDS  357 

twelfth  day.  It  is  especially  likely  to  occur  in  connection 
with  septic  pneumonia;  and  when  it  so  appears  it  is  to  be 
regarded  as  an  indication  of  a  fatal  termination.  In  most 
instances  other  signs  of  sepsis  will  be  present  and  the 
yellow  skin  be  of  minor  importance. 

The  treatment  is,  naturally,  that  for  septicemia  in  gen- 
eral: eliminative  and  supportive,  with  absolutely  perfect 
drainage  of  wound  if  possible. 

3.  Acute  yellow  atrophy  of  the  liver  is  a  condition  which 
very  rarely  follows  the  prolonged  use  of  chloroform,  the 
theory  of  its  production  being  that  the  chloroform  is  re- 
tained in  the  liver  in  large  quantities,  combining  with  the 
lecithin  and  cholesterin  therein  present.  Pregnant  women, 
past  the  fourth  month  of  gestation,  are  more  often  affected 
than  any  other  patients.  It  may  occur  as  the  direct  result 
of  sepsis,  but  cases  have  been  reported  without  septic 
infection.  By  some  it  has  been  believed  to  occur  only  in 
patients  suffering  from  syphilis;  but  two  of  my  cases  were 
in  non-luetic  subjects. 

The  trouble  begins  with  continued  nausea  and  other 
signs  of  gastric  irritation,  icterus  making  its  appearance 
on  the  third  day  or  later;  and  by  the  time  the  skin  becomes 
quite  yellow  the  patient  is  semicomatose  with  restlessness 
(i.  e.,  stupor  with  delirium)  and  even  mild  mania  may  be 
present.  Soon  after  this,  convulsions  may  appear  and 
fatal  coma  supervene.  Recovery  is  exceedingly  rare; 
though  a  few  cases  have  been  known  to  present  the  typical 
symptoms  of  jaundice,  marked  diminution  of  the  liver- 
dulness,  pain  in  region  of  liver,  bloody  vomiting,  bloody 
stools,  nose-bleed,  stupor,  subnormal  temperature,  etc.,  and 
yet  not  end  in  death.  Jaundice  may  be  very  pronounced; 
yet  in  cases  of  speedy  dissolution  there  may  be  time  for 
only  a  slight  change  in  color.  The  spleen  is  usually 
enlarged.  Hemorrhagic  ecchymoses  in  the  skin  have  been 
noted. 


358  SURGICAL  THERAPEUTICS 

Treatment  consists  in  thorough  evacuation  of  the 
bowels  followed  by  large  doses  of  the  phenolsulphonates 
(sulphocarbolates)  of  zinc  and  sodium,  naphthalin  or  salicy- 
late  of  phenol  (salol)  every  hour  or  two.  Nutrient  enemata 
are  of  importance.  Diuretics  are  especially  indicated. 
Small  doses  of  calomel  (half  a  centigram,  or  gr.  1-6)  every 
hour  are  highly  praised.  For  the  restlessness  gram-doses 
of  sodium  bromide  either  by  mouth  or  rectum,  prove  most 
satisfactory.  When  stupor  becomes  marked,  hypodermo- 
clysis  is  to  be  employed:  one  liter  (quart)  of  normal  salt 
solution  to  be  injected  in  the  buttocks  or  breasts  twice 
daily. 

4.  It  is  a  peculiar  fact  that  sometimes  the  existence  of 
jaundice  is  not  suspected  until  the  first  incision  is  made. 
Then  the  intense  yellowness  of  the  fat  and  the  tendency 
to  bleed  excessively  shows  that  icterus  is  present,  though 
the  discoloration  of  skin  and  conjunctiva  had  not  been 
sufficiently  decided  to  attract  attention.  While  this  con- 
dition of  affairs  is  not  strictly  a  postoperative  jaundice, 
the  friends  of  the  patient  will  so  regard  it  with  anxiety, 
because  the  yellow  color  soon  becomes  intensified. 

So  far  as  the  surgeon  is  concerned  it  means  chiefly  more 
care  in  hemostasis.  Not  only  is  there  great  tendency  to 
bleed  during  the  operation  but  oozing  from  the  wound  may 
give  trouble  for  days  afterwards ;  notably  so  when  drainage 
is  practised.  To  check  this,  4  grams  (grs.  60)  of  calcium 
chloride  may  be  given  by  rectum  three  times  a  day  until 
the  tendency  to  bleed  is  arrested.  To  the  wound  itself  a 
solution  of  antipyrin  (1:50)  may  be  applied  freely;  but 
tight  packing  generally  controls  the  oozing. 

Postoperative  Pain. — One  of  the  principal  objections 
against  operative  treatment,  on  the  part  of  patients,  is  the 
pain  which  is  presumed  to  follow  surgical  work.  With  the 
wide  adoption  of  hyoscine-morphine  anesthesia  this  will, 
in  great  measure,  pass  away,  because  this  form  of  surgical 


WOUNDS  359 

anesthesia  gives  many  hours  of  perfect  comfort  after  the 
patient  leaves  the  operation-room.  But  when  ether  or 
chloroform  is  used  there  is  a  period  of  some  hours  during 
which  there  is  often  much  suffering. 

The  tendency  of  most  surgeons  is  to  use  morphine 
hypodermically  freely  for  this  postoperative  pain — entirely 
too  freely  in  many  instances.  There  are  cases  in  which  it 
is  demanded;  but  in  abdominal  surgery  it  is  objectionable, 
first,  because  it  increases  the  tendency  to  vomit  and  second, 
because  it  checks  the  secretions  and  arrests  peristalsis. 
Of  course,  when  there  is  a  wounded  intestine  (as  in  appen- 
dicitis) and  adhesions  are  desirable,  morphine  must  be 
given;  not  so  much,  however,  to  arrest  pain  as  to  prohibit 
peristalsis. 

In  other  cases  the  milder  and  far  less  objectionable 
codeine  may  be  used,  the  rule  being  to  inject  one  grain 
(Gm.  0.07)  of  the  phosphate,  and  repeat  it  in  one,  two  or 
three  hours,  as  needed,  to  make  the  patient  comfortable. 
The  phosphate  of  codeine  is  preferable  to  the  common 
sulphate  because  it  is  more  freely  soluble  in  water  than 
any  of  the  other. 

To  quiet  nervousness,  an  enema  of  i  gram  (grs.  15) 
each  of  potassium  bromide  and  chloral  hydrate  is  far 
superior  to  any  opiate. 

Postoperative  Pulmonary  Embolism. — Thrombosis 
and  embolism  are  more  common  after  operations  in  the 
pelvis  than  after  operations  in  any  other  part  of  the  body.- 
In  a  resume  of  7130  gynecological  operations  Schenck  re- 
ports 48  cases  of  thrombosis.  The  symptoms  are  as  fol- 
lows: The  attack  is  characterized  by  precordial  distress, 
severe  pain  and  dyspnea,  associated  with  quickened  pulse; 
the  patient  has  an  extremely  anxious  expression,  gasps 
for  breath  with  the  aid  of  all  the  auxilliary  respiratory 
muscles;  the  face  becomes  cyanosed;  cold,  clammy  sweat 
occurs;  the  mind  remains  clear,  as  a  rule,  and  death 


360  SURGICAL  THERAPEUTICS 

occurs    in    a  few   minutes,    in   spite   of   energetic    stimu- 
lation. 

Postoperative  Shock. — Shock  immediately  following 
operation  depends  upon: 

1.  Excessive  hemorrhage. 

2.  Too  much  chloroform  or  ether. 

3.  Injury  to  important  nerves. 

4.  Fear  of  death. 

Theoretically  there  is  a  difference  between  "collapse" 
due  to  loss  of  blood  and  "shock"  dependent  upon  some 
tremendous  depressing  influence  upon  the  nerve-centers; 
practically  there  is  none. 

The  first  variety  is  characterized  by  loss  of  pulse,  by 
gasping,  by  paleness  and  clamminess  of  the  skin. 

The  second  form  is  recognized  by  disturbance  in  respira- 
tion, by  irregular  or  imperceptible  pulse,  by  coldness  of 
extremities,  and  by  widely  dilated  pupil. 

The  third  is  distinguished  by  a  peculiar  lividity  of  the 
face,  pinched  expression,  quickened  and  shallow  respira- 
tion, and  the  peculiar  restlessness  which  so  often  immedi- 
ately precedes  death  in  one  who  is  partly  conscious. 

In  the  first  form,  especially,  and  in  the  second  also, 
sometimes  the  evidences  of  shock  appear  without  warning. 
Everything  seems  to  be  progressing  well  during  operation, 
when  suddenly  an  assistant  exclaims,  "The  patient  is  not 
doing  well" — and  operation  has  to  be  brought  to  a  hurried 
end  in  order  to  prevent  death  upon  the  table. 

In  other  instances  everything  may  have  gone  well  at 
operation,  with  considerable  anxiety  as  to  shock  because 
either  of  excessive  loss  of  blood  or  prolonged  and  serious 
operative  work,  and  a  little  while  after  the  patient  has  been 
put  in  bed  the  pulse  becomes  thready,  the  respiration  shal- 
low and  irregular  and  the  extremities  cold — a  condition 
extremely  common  when  the  anesthetist  has  been  too  free 
with  the  chloroform,  and,  in  less  degree,  wkh  ether.  With 


WOUNDS  361 

the  adoption  of  the  hyoscine-morphine  form  o  surgical 
anesthesia  shock  is  practically  eliminated,  save  that  form 
dependent  upon  excessive  blood-loss;  even  the  severance 
of  huge  nerve-trunks  does  not  change  the  frequency  of 
pulse  or  of  respiration  as  it  does  under  the  older  forms  of 
anesthesia. 

Prevention. — The  most  important  prophylactic  of  shock, 
then,  is  the  selection  of  the  anesthetic.  If  a  child  is  to 
be  operated  upon,  if  the  work  is  to  be  of  only  short  dura- 
tion or  if  the  subject  is  of  advanced  age,  chloroform  is  to 
be  selected.  If  the  operation  is  upon  some  other  who  is 
not  a  fit  subject  for  hyoscine-morphine  injection,  ether  is 
to  be  preferred.  But  whenever  possible,  two  doses  of  the 
hyoscine-morphine  injection  should  be  given,  supple- 
mented at  the  proper  time  by  a  little  cocaine  locally  or  the 
inhalation  of  a  few  drops  of  chloroform  or  ether;  or  in 
proper  cases  three  full  doses  of  the  anesthetic  tablet  may  be 
employed,  with  excellent  anesthesia  and  surprising  free- 
dom from  shock,  except  such  as  may  possibly  result  from 
loss  of  blood. 

The  next  consideration  is  conservation  of  the  strength 
of  the  patient.  If  there  be  extreme  weakness  and  the 
general  condition  may  be  improved  by  waiting  it  is  better 
to  put  off  the  operation  until  proper  treatment  may  be 
given.  Entirely  too  many  patients  weakened  by  prolonged 
suffering  are  admitted  to  hospitals  on  one  day  and  sub- 
jected to  operation  the  next.  Forced  feeding  for  three  or 
four  days,  with  injection  of  2  milligrams  (gr.  1-34)  of 
strychnine  every  six  hours,  will  do  much  to  ward  off  shock. 
The  use  of  an  ounce  of  whisky  a  few  hours  before  opera- 
tion is  a  good  thing  in  some  cases.  With  the  hypodermic 
form  of  anesthesia,  too,  the  patient,  if  extremely  weak, 
may  be  given  a  little  food  two  hours  before  the  first  in- 
jection, so  that  the  weakness  of  fasting  is  not  added  to  that 
of  disease  and  operation. 


362  SURGICAL  THERAPEUTICS 

Treatment. —  (i)  The  treatment  of  the  first  kind  of 
shock  differs  in  marked  degree  from  that  appropriate  to 
the  others.  Here  the  use  of  hypodermoclysis  is  to  be  com- 
mended: the  injection  of  a  liter  (quart)  of  salt  water 
under  the  skin  soon  restores  the  amount  of  blood-serum  to 
something  near  the  normal.  If  this  is  done  while  the  opera- 
tion is  still  being  performed,  great  care  must  be  exercised 
not  to  soil  the  field  of  work  nor  to  dirty  the  hands  of  the 
surgeon  which  may  be  close  by. 

As  soon  as  it  is  seen  that  shock  is  appearing  the  pa- 
tient's head  must  be  lowered  so  that  profound  anemia  of 
the  brain  may  not  cause  death.  If  the  shock  occurs  during 
operation  the  Trendelenburg  position  must  be  adopted, 
though  not  to  an  exaggerated  degree;  after  the  patient 
has  been  returned  to  bed,  the  foot  of  the  bed  should  be  put 
on  a  chair  so  that  for  several  hours  gravity  helps  to  coun- 
teract shock;  and  no  pillow  should  be  allowed  beneath 
the  head.  In  extreme  cases  both  legs  may  be  bandaged 
from  the  toes  upward  to  the  hips  to  force  most  of  the  blood 
into  the  abdomen,  chest  and  head;  and  the  arms  may  be 
held  up  by  the  nurses.  No  doubt  many  lives  might  be 
saved  by  resorting  to  these  simple  measures  if  surgeons 
would  but  take  the  trouble  to  give  the  necessary  instruc- 
tions and  then  see  that  they  are  carried  out. 

As  soon  as  possible  artificial  heat  must  be  applied — 
hot  water-bags  or  bottles  being  placed  around  the  body 
and  legs  of  the  patient,  and  blankets  applied  so  as  to  re- 
tain the  heat. 

Here  the  hypodermic  use  of  strychnine  can  do  no  good 
— and  it  may  do  harm.  Glonoin  in  dose  of  one  milligram 
(or  gr.  i-ioo  tablet)  either  under  the  tongue,  whence  it  is 
almost  instantly  absorbed,  or  hypodermically  will  do  more 
good  than  anything  else  medicinally.  After  a  few  minutes 
digitalin  may  be  injected,  and  still  later,  if  the  pulse  flags, 
10  minims  of  camphorated  oil  may  be  injected. 


WOUNDS  363 

If  the  shock  continues  for  some  hours,  hypodermoclysis 
may  be  repeated,  using  the  buttocks  instead  of  the  mam- 
mary region;  and  rectal  injection  of  hot  salt  solution  may 
be  given  also;  or  better,  hot  water  with  or  without  a  little 
beef  extract;  and  in  some  cases  hot  coffee. 

As  the  shock  disappears  the  bandages  may  be  removed 
from  the  extremities;  later  the  bed  may  be  lowered  to  the 
level ;  and  finally  a  pillow  may  be  allowed. 

2.  The  treatment  of  shock  dependent  in  great  measure 
upon  excess  of  anesthetic  must  of  necessity  differ  from  that 
just  described. 

In  the  first  place,  unless  there  has  been  decided  loss  of 
blood  also,  the  injection  of  normal  salt  solution  is  quite 
unnecessary,  even  if  not  harmful.  In  the  second  place, 
the  indications  are  squarely  to  counteract  the  effect  on  (a) 
the  respiration  and  (b)  the  circulation. 

If  the  trouble  is  discovered  while  the  patient  is  still  on 
the  operation-table  the  anesthetic  (if  an  inhalant  one) 
must  be  discontinued  instantly  and  the  work  completed 
as  speedily  as  possible.  If  respirations  cease,  artificial 
respiration  must  be  instituted  and  maintained  for  hours, 
if  necessary — many  lives  have  been  sacrificed  by  too  early 
discontinuance  of  artificial  respiration.  One  hour  is  the 
shortest  excusable  time  for  cessation  of  efforts  to  induce 
respiration.  The  sphincter  ani  may  be  forcibly  dilated. 
When  respiration  has  been  restored  it  is  best  to  finish  the 
operative  work,  if  possible,  since  it  may  be  days  before 
the  conditions  would  warrant  the  administration  of  an 
anesthetic  again.  But  cocaine  should  not  be  injected 
(as  has  been  suggested  by  someone)  since  it  has  a  ten- 
dency to  produce  cerebral  anemia — sometimes  of  alarm- 
ing degree. 

The  head  may  be  depressed  in  this  form  of  shock,  also, 
with  advantage;  and  if  oxygen  be  at  hand,  its  inhalation 
is  excellent  in  effect. 


364  SURGICAL  THERAPEUTICS 

Here  strychnine  hypodermically  is  of  advantage;  and 
if  the  face  be  pale,  glonoin  may  precede  it.  Failing  pulse, 
after  return  to  bed,  calls  for  camphorated  oil. 

An  enema  of  a  pint  of  strong  coffee  is  of  decided  ad- 
vantage in  awakening  one  too  deeply  asleep  from  any 
anesthetic.  It  is  notably  indicated  in  prolonged  sleep, 
with  shock,  following  the  use  of  hyoscine-morphine  injec- 
tion. 

Inhalation  of  ammonia  is  also  of  use  in  arousing  pa- 
tients. 

Early  administration  of  small  quantities  of  champagne 
(or  diluted  whisky)  by  the  mouth  is  ^advisable. 

When  the  heart's  action  continues  weak  for  a  long 
period  large  doses  (4  grams,  or  i  teaspoonful)  of  spiritus 
setheris  compositus  may  be  given  every  hour,  properly 
diluted. 

3.  When  shock  comes  on  immediately  after  extensive 
trauma  (as  at  the  end  of  an  amputation  of  the  breast  or 
extirpation  of  a  huge  fibroid)  without  excess  of  anesthetic 
or  great  bleeding,  its  character  should  be  instantly  recog- 
nized and  proper  measures  immediately  adopted.  If  it 
appears  soon  after  the  patient  has  been  returned  to  bed 
it  might  be  mistaken  for  concealed  hemorrhage;  but  the 
prostration  is  different,  the  veins  are  prominent  with  cya- 
nosis, there  is  restlessness,  etc.,  which  make  the  kind  of 
shock  usually  recognizable. 

In  this  condition  the  Trendelenburg  position  does  no 
good.  A  hot  water-bag  placed  over  the  heart  seems  to 
be  of  service.  Warmth  to  the  extremities  is  imperative. 

A  hypodermic  injection  of  atropine  will  send  the  blood 
out  of  the  deep  structures  into  the  capillaries. 

It  may  be  followed  in  a  few  minutes  by  one  milligram 
(gr.  1-67)  of  digitalin. 

Thirty  drops  of  a  i  :  1000  solution  of  adrenalin  by  mouth 
every  half  hour  until  reaction  sets  in  is  highly  recommended. 


WOUNDS  365 

Sparteine  in  doses  of  half  a  decigram  (gr.  3-4)  may  be 
injected  an  hour  after  the  digitalin  is  given. 

An  enema  of  salt  solution,  very  hot,  often  helps  to  revive 
a  patient  apparently  near  to  death;  or  hot  coffee  may  be 
substituted. 

4.  Shock  due  to  fear — the  "nervous  collapse"  of  some 
authors — is  totally  eliminated  by  the  use  of  the  hyoscine- 
morphine  combination  for  surgical  anesthesia.  The  perfect 
tranquillity  for  hours  following  operation  is  in  striking 
contrast  to  the  anxiety,  nervousness  and  discomfort  of  the 
early  hours  following  the  ordinary  anesthesia  by  ether  or 
chloroform. 

When  the  older  form  of  anesthesia  is  employed,  however, 
shock  sometimes  does  occur,  the  collapse  usually  making  its 
appearance  several  hours  after  completion  of  the  work. 

A  small  dose  of  codeine  phosphate  hypodermically 
(half  a  decigram,  gr.  3-4)  either  alone  or  with  2  centigrams 
(gr.  1-32)  of  strychnine  generally  calms  the  patient  and 
allows  the  circulation  to  resume  its  normal  character. 

If  the  nervousness  continue,  however,  an  enema,  con- 
taining one  and  a  half  gram  (grs.  20)  of  potassium  bromide 
and  one  decigram  (gr.  i  1-2)  of  aqueous  extract  of  opium, 
may  be  given  and  the  patient  left  alone. 

Postoperative  Thirst. — While  postoperative  thirst 
is  not  so  distressing  after  hyoscine-morphine  anesthesia 
as  under  the  old  ether  and  chloroform  narcosis,  it  still  is 
a  matter  of  importance,  particularly  in  abdominal  surgery 
where  it  is  often  desirable  that  twenty-four  hours  shall 
elapse  before  anything  is  taken  into  the  stomach.  It  is 
especially  pronounced  when  there  has  been  great  loss  of 
blood,  unless  the  normal  amount  of  serum  has  been  partly 
restored  by  hypodermoclysis. 

To  overcome  this  thirst  a  liter  (quart)  of  water  may  be 
injected  into  the  rectum  or  colon  unless  some  special  con- 
traindication exists;  preferably  just  after  the  patient 'has 


366  SURGICAL  THERAPEUTICS 

been  returned  to  bed.  When  thirst  becomes  urgent, 
moistening  the  lips  and  tongue  frequently  with  a  cloth 
dipped  in  ice-water  is  a  most  comforting  expedient;  but 
the  patient  should  not  be  permitted  to  suck  ice,  since 
holding  bits  of  ice  in  the  mouth  above  all  other  things 
increases  the  tendency  to  vomit.  Later  a  little  juice  of 
lemon  may  be  permitted — it  helps  to  appease  thirst  remark- 
ably. In  ordinary  cases  a  teaspoonful  of  water  every 
fifteen  minutes  may  be  given  after  the  first  four  or  five  hours ; 
in  abdominal  sections  after  twelve  hours,  unless  vomiting 
occur — if  it  does,  twenty-four  hours  must  be  allowed  to 
pass  before  a  drink  is  permitted. 

When  thirst  causes  great  restlessness  and  nervousness 
a  capsule  of  5  grains  of  chloretone  with  a  little  sip  of  water 
seems  to  give  great  relief.  After  twenty-four  hours,  if 
vomiting  does  not  occur,  cold  water  may  be  allowed  freely, 
save  in  the  most  exceptional  cases,  as  where  there  is  too 
free  drainage  from  the  abdomen. 

Postoperative  Vomiting. — Vomiting  immediately 
after  an  operation  usually  means  nausea  from  the  anesthetic. 
Persisting  for  one  or  two  days  it  may  be  but  a  con- 
tinuation of  this  nausea,  or  it  may  depend  upon  oncom- 
ing sepsis.  Vomiting  beginning  twenty-four  to  forty-eight 
hours  after  operation  generally  indicates  acute  sepsis. 

With  the  use  of  ether,  retching  and  distressing  nausea 
(and  sometimes  vomiting)  may  persist  for  many  hours  in 
spite  of  the  utmost  care  as  to  proper  preparation.  When 
chloroform  is  employed  there  may  be  no  great  nausea  with 
children  or  with  other  patients  if  the  operation  be  of  short 
duration;  but  if  anesthesia  is  prolonged  there  is  apt  to  be 
very  distressing  vomiting  for  many  hours.  When  it  is 
anticipated  that  the  operative  work  will  be  long-continued, 
one  gram  (grs.  15)  of  chloretone  maybe  given  an  hour  before 
operation,  by  the  mouth;  this  greatly  diminishes  the  ten- 
dency to  postoperative  vomiting. 


WOUNDS  367 

With  the  use  of  the  hyoscine-morphine  anesthesia  there 
is  practically  no  nausea  or  vomiting,  even  though  only 
two  doses  are  given,  supplemented  by  a  little  chloroform. 

In  the  treatment  of  vomiting  due  to  the  anesthetic  the 
first  thing  is  to  have  the  patient  keep  quiet;  nervousness 
and  an  inclination  to  talk  unquestionably  increases  the 
tendency  to  vomit.  The  next  thing  of  importance  is  to 
withhold  water,  so  long  as  nausea  persists  nothing  should 
be  taken  into  the  stomach.  Holding  ice  in  the  mouth  only 
increases  nausea. 

Rarely  (especially  after  ether),  when  the  patient  is 
retching  and  straining  it  is  a  good  plan  to  give  a  pint  or 
more  of  water  at  once  and  let  the  patient  throw  off  this; 
then  abstain  from  water  for  some  hours.  The  application 
of  an  ice-bag  to  the  throat  seems  to  diminish  nausea,  par- 
ticularly with  nervous  women. 

If  the  vomiting  continue  more  than  twelve  hours  it  is 
best  to  wash  out  the  stomach  by  passing  a  stomach-tube 
and  pouring  in  a  liter  (quart)  of  normal  salt  solution;  and 
if  early  catharsis  is  desired,  leaving  a  large  dose  of  epsom 
salt  in  the  stomach  before  removing  the  tube. 

If  the  emesis  becomes  alarming,  four  hypodermic  in- 
jections of  eserine  salicylate  should  be  made,  using  one 
milligram  (gr.  1-67)  every  hour.  This  generally  arrests 
the  vomiting,  even  from  obstruction  of  the  bowels,  and 
makes  the  patient  more  comfortable  than  will  any  form 
of  opiate. 

Sometimes,  when  the  vomiting  is  dependent  principally 
upon  nervousness,  a  clyster  containing  one  gram  (grs.  15) 
each  of  chloral  hydrate  and  potassium  bromide  in  starch 
water  will  not  only  check  it  but  give  four  or  five  hours  of 
sleep,  from  which  the  patient  awakens  refreshed  and  calm. 

As  soon  as  the  ejecta  change  from  bile-stained  fluid  to 
dark,  greenish  brown  there  is  acute  sepsis  present,  and 
proper  attention  must  at  once  be  directed  to  correction  of 


333  SURGICAL  THERAPEUTICS 

the  cause  of  trouble — preceded,  always,  by  lavage  of  the 
stomach  and  stimulation  to  the  highest  possible  degree; 
for  without  energetic  measures  "black-vomit"  means 
death. 

WRIST:    GANGLION  OF 

A  wrist  ganglion  is  a  hernial  pouch  of  a  tendon  sheath 
upon  the  back  of  the  wrist.  It  may  be  treated  the  same 
as  ganglion  elsewhere,  though  with  even  more  strict  anti- 
septic precautions  on  accoun  of  the  danger  of  infecting 
the  joint.  (See  ganglion). 

X-RAY 

X-Ray  Barns. — For  the  simple  dermatitis  following 
too  severe  application  of  x-radiance,  some  simple,  bland 
ointment  (like  unguentum  aquae  rosae  or  zinc  ointment)  is 
best;  antiseptics,  even  of  mild  strength,  irritate  too  much. 
Nature  usually  takes  care  of  the  case  in  a  few  days  or 
weeks.  But  only  too  often  pain  becomes  more  and  more 
pronounced  and  a  slough  appears,  with  great  prostration 
and  loss  of  flesh.  It  is  well,  upon  the  first  appearance 
of  pain,  to  anesthetize  the  patient  and  clean  the  field  care- 
fully without  chemical  irritants;  estimate  the  amount  of 
slough,  and  make  a  wide  incision,  and  remove  all  tissue 
until  a  good  supply  of  blood  is  found. 

If  the  burn  appears  in  a  favorable  place  ordinarily  the 
incision  should  be  carried  about  five-eighths  of  an  inch  in 
depth,  giving  an  ordinary  wound  that  will  granulate  readily 
and  will  be  without  the  terrible  pain  which  accompany 
most  of  the  burns.  This,  of  course,  cannot  he  done  readily 
on  the  feet  and  hands,  owing  to  a  lack  of  tissue,  so  that 
recourse  must  be  had  to  the  use  of  drugs  or  procedures  that 
will  promote  healing  and  allay  the  pain. 

The   use   of   normal   salt   solutions   sometimes   works 


X-RAY  369 

wonders  as  a  moist  dressing.  Once  in  a  while  warm  boric 
acid  solution  may  be  used  with  comfort.  Aseptic  blood 
preparations  or  sterilized  milk  with  a  boric-acid  preserva- 
tive may  be  used,  but,  as  a  general  proposition,  ointments, 
etc.,  are  objectionable,  and  tend  to  aggravate  the  pain. 
Frequent  and  deep  cureting  is  indicated  if  the  ulcer  become 
chronic  and  should  be  carried  out  as  long  as  the  yellowish 
white  membrane  exists  in  the  wound. 

X-Ray  Treatment  of  Cancer. — One  of  the  best 
and  most  impartial  observers,  Williams,  of  Richmond, 
after  long  trial  and  careful  study  reaches  the  conclusion 
that  for  superficial  malignant  growths,  unless  they  have 
invaded  adjacent  bones  and  cartilages,  the  ray  should 
be  used  because  when  rightly  applied  the  result  is  so 
uniformly  successful.  Its  application  is  painless,  there 
is  less  scar  and  deformity  and  a  recurrence  is  in  propor- 
tion to  the  thoroughness  of  the  treatment.  Carcinomas 
on  the  lip  or  connected  with  any  mucous  membrane  should 
be  excised,  because  for  some  reason  they  seem  to  be  espe- 
cially resistant  to  the  ray. 

For  malignant  growths  of  the  deeper  structures, 
including  the  breast,  radical  surgical  procedure  should 
be  recommended,  always.  It  is  but  rational  that  the 
surgical  operation  should  be  followed  by  sufficient  expos- 
ures to  the  ray  to  destroy  malignant  cells  that  have  been 
left.  It  is  possible  to  destroy  such  cells  an  inch  or  two 
from  the  surface,  and  the  patient  should  have  every  pos- 
sible chance  to  have  the  malignant  cells  completely  eradi- 
cated or  destroyed.  Recurrent  growths  of  the  breast 
often  yield  readily  to  x-ray  treatment  because  the  recur- 
rence is  so  near  the  surface.  The  prognosis  in  these  cases 
depends  on  whether  the  neighboring  glands  or  the  thoracic 
cavity  are  invaded.  Morton,  of  New  York  recently 
said  that  his  opinion  of  the  status  of  the  x-ray  is  that  it 


370 


SURGICAL  THERAPEUTICS 


is  at  a  period  of  partial  therapeutic  eclipse  by  reason 
of  its  being  abused  by  ignorant  workers.  Many  doctors 
think  that  all  they  have  to  do  is  to  buy  a  machine  and 
administer  the  x-ray  to  get  cures.  As  to  the  particular 
radiation  that  comes  out  of  a  tube,  he  believes  in  ,he 
therapy  of  a  high  vacuum  tube,  7  to  12  inches  alternating 
spark,  because  we  have  to  deal  not  with  deep  lesions  only, 
but  with  intermediate  lesions  as  well  as  superficial.  A  tube 
that  gives  no  yellow  color  whatever  is  the  safest;  it  obliter- 
ates the  chance  of  injury  to  the  patient  and  gives  the 
best  therapeutic  effect. 


INDEX 


Abdomen,  Actinomycosis  of 29 

Distension  of 321 

Abdominal   Pain   in   Shock    286 

Section i 

Calomel  after 2 

Chronic  Obstruction    after 18 

Codeine  after 3 

Elaterin  after 3 

Enemas   after 4 

Eserine  Salicylate  in    13 

Fowler's  Position  after 6 

Hypodermic  Stimulation 1 1 

Hypodermoclysis  in 10 

Lung  Complications  after 232 

Obstruction  of  Bowels  after 12 

Opium  after 4 

Peritonitis  following 4 

Phlebitis  after 1 1 

Preparation  for  19 

Secondary 9 

Shock  after 10 

Stomach  Irritation  after 8 

Tumors I 

Wall,  Abscess  of 240 

Abscess   20 

Alveolar 20 

Anal 74 

Atheromatous 90 

Bursal 20 

Cerebral    21 

Cold 21 

Colon  Bacillus 23 

Fecal 21 

Irrigation  of 26 

Lid 230 

Liver   231 

Mammary 22 

Metastatic 22 

Pain  of  22 

Psoas 22 

Retrorectal   273 

Spinal    23 


372  INDEX 

Abscess,  Splenic    '. 291 

Stitch 23 

Thecal 24 

Tropical    24 

Tubercular 25 

A.  C.  E.  Mixture 37 

Acetonuria   26 

Achondroplasty   28 

Acne  of  Neck,  Furunculous 242 

Acromegalia 28 

Acromion,   Caries  of   126 

Fracture  of    163 

Actinomycosis 28 

of  Abdomen 29 

of  Appendix 29 

Bovis 92 

Adenitis 30 

Adenoids     32 

Adenoma 33 

Adhesions  in  Abdominal  Surgery i 

Ainhum 33 

Alveolar  Abscess 20 

Cancer  116,  124 

Amputation  in  Diabetic  Gangrene 1 74 

Amputations 34 

Anam  Ulcer 35 

Anesthesia 35 

Accidents  of 44 

A.  C.  E 37 

Brucine  35 

Chloroform '. 38 

Cocaine 37 

Combined 37 

Ether 37 

Ethyl  Chloride 38 

Heart-failure 55 

H-M-C    47 

H-M-C,  Precautions  in 59 

Local 35 

Lumbar 63 

Phenol 65 

Scopolamine 47 

Shock  from    364 

Tropacocaine  63 

Vomiting  after 66 

Vomiting  during  45 

Anesthetic,  Phenol  as  a  Local 65 

Aneurism    67 

of  Aorta   67 

Calcium  Chloride  for   68 

Iodides  for , 68 

Threatened  Rupture  of 69 


INDEX  373 

Angioma 69 

Ankle,  Diseases  of 70 

Sprained   70 

Ankylosis    219 

.    from  Hemophilia 194 

Ankylosing  Synovitis    222 

Anthracemia 71 

Anthrax 71 

Antiseptic,  Bichloride  as  an    97 

.    Dusting  Powder   72 

Phenol  as  an 72 

Solution,  Harrington's 73 

Solutions 72 

Thymol  as  an 74 

Anuria  in  H-M-C  Anesthesia 55,  74 

after  Operation 244 

Postoperative   74 

Sparteine   for    55,  75 

Anus,  Abscess  of   75 

Artificial 76 

Cancer  of 76 

Chancre  of 76 

Diseases  of 75 

Fissure  of   76,  197 

Fistula  of  78 

Imperforate 78 

Polyps  of   79 

Prolapse   of    79 

Pruritus  of    79,  268 

Aorta;  Aneurism  of 67 

Inflammation  of   80 

Aortitis,  Acute 80 

Appendectomy,  Treatment  after 85 

Appendicitis  80 

Actinomycotic    29 

Bowel  Movement  in    81 

Distension  in 82 

Fever  in   81 

Hernia  with 83 

Nonoperative  Treatment 81 

Pain  in   81 

Peritonitis  with   84 

Postoperative  Treatment 85 

Pregnancy  with 83 

Treatment  after    85 

Tumor  of 83 

Vomiting  in   82 

Appendix,  Actinomycosis  of 29 

in  Hernia  Sac   83 

Apoatropine  in  Anesthetics    51 

Arteries,  Diseases  of   86 

Inflammation  of   86 


374  INDEX 

Arteries — Wounds  of 86 

Arteritis 86 

Arthritis    87 

Deformans    87,  221 

Fungosa 221 

Infective    218 

Uritica 221 

Arthropathy  87 

Ascites 89 

Aspirator,  Use  of 90 

Atheroma 90 

Autosuggestion  after  Injury '. 91 

B 

Bacilli    92 

Back,  Sprains  of 91 

Ache  after  Operation    244 

Bacteria  of  Surgery  92 

Balanitis 95 

Balanoposthitis    95 

Balsam  of  Peru  for  Wounds 335 

Bandage,  Martin's   227 

Basedow's  Disease   182 

Bed   Sores    96 

Bee  Stings   96 

Belladonna  for  ..Carbuncle 123 

Bichloride  Solutions 97 

Bier's  Treatment  of  Inflammation 212 

Biliary  Colic 171,  173 

Bites 289 

Black  Eye   98 

Leg 71 

Vomit 98 

Vomit  after  Operation    245 

Bladder,  Atony  of  98 

Atrophy  of 146 

Carcinoma  of   102 

Catarrh  of   99 

Cysts  of   102 

Diseases  of    98 

Extrophy  of gg 

Fibroma  of    102 

Hernia  of 99 

Inflammation  of 99,   143,  345 

Inversion  of 99 

Irritable    99 

Myoma  of   102 

Nervous    100 

Papilloma  of 102 

Paralysis  of  100 

Prolapse  of 100 


INDEX  375 

Bladder,  Sacculated 101 

Sarcoma   of    102 

Stone  in   101 

Treatment   after  Operation  on 101 

Tuberculosis  of 102 

Tumors  of  102 

Ulcer  of   103 

Wounds  of 104 

Bleeders 193 

Bleeding   195 

Internal 195 

Blepharadenitis    104 

Blepharitis    104 

Blepharoadenoma   104 

Blepharoedema    104 

Blisters    105 

Blood  Poisoning   282 

Transfusion  of 105,  310 

Bockhart's   Blood-serum   Mercury    106 

Boils 106 

Compared  with  Carbuncles 107 

Prevention  of 108 

Bones,  Caries  of 125 

Diseases  of no 

Necrosis  of . 125 

Bowel,  Obstruction  of 12,  333 

Bowels,  Treatment  after  Operation  for  Obstructed 213 

Bow  Legs no 

Brain,  Hernia  of 203 

Breast,    Cancer  of    in 

Diseases  of in 

Breasts,  Inflammation  of   1 1 1 

Blight's  Disease    112 

Bronchocele    181 

Brooke's  Formula  for  Lupus 234 

Brucine  for  Local  Anesthesia 35 

Bubo   112 

Buboes,   Chancroidal   —  131 

Phenol  for   112 

Sympathetic   113 

Treatment  of 113 

Welander's  Treatment  of   113 

Bubonocele     112 

Burns 114 

Phenol   for   1 14 

X-Ray 369 

Bursa,  Inflammation  of 115 

Bursal  Abscess 20 

Bursitis 115 


376  INDEX 


Calcium  Chloride  for  Aneurism   68 

Iodide  for  Ulcers   327 

Sulphide  in  Suppuration 300 

Calculus,  Urinary  223* 

Calomel  in  Abdominal  Surgery 2 

Campho-phenol  Solution     342 

Cancer  116,  124 

and  Moles   ,   238 

Condurango  for 1 18 

of  Anus 76 

of  Breast in 

of  Rectum 274 

of  Stomach 270,  296 

Marsden's  Paste  for 1 19 

Methylene  Blue  for 1 19 

Prevention  of 120 

Radium  Treatment  of   121 

X-Ray  for   < 368 

Cancrum  Oris 122 

Bacillus  of 93 

Canker 121 

Carbolic   Acid   Gangrene    1 74 

Carbuncle 123 

Belladonna  for 123 

Carbuncles  and  Boils 107 

of  Eyelid    : 104 

Treatment  of : 107 

Carcinoma     1 1 6,   1 24 

Tuberosum 124 

Caries    125 

Cartilage,  Disease  of 126 

Castor   Oil,  Pleasant  127 

Cataplasma  Kaolini  248 

Cataphoresis,  Cocaine  by 35 

Catgut,  Iodized 127 

Cerebral  Abscess 21 

Hernia 203 

Cervical  Ribs 128 

Cessation  of  Respiration  in  Chloroform  Anesthesia 44 

Chancre 128 

of  Anus 76 

Chancroids 129 

Charcoal  Poultices   266 

Charcot's  Joint  87 

Chilblains 131 

Chloroform  Anesthesia   38 

Dropper    40 

Mask 42 

Vomiting 45 

Chlorophenol 258 


INDEX  377 

Cholangitis  132 

Cholecystitis 132 

from  Typhoid   135 

Cholecystostomy,   Treatment  after   135 

Choledochitis   172 

Chondralgia   126 

Chondritis 127 

Chondrosarcoma   127 

Chordee 136 

Prevention   of    136 

Cicatrices    279 

Cicatricial  Deformities 137 

Cionitis   137 

Circumcision 137 

Cirrhosis  of  Liver 231 

of  Liver,   Operation  for 307 

Clap 185 

Chronic 180 

Clark's  Treatment  of  Peritonitis 5 

Cleaning  Hands  Quickly    191 

Cocaine  by   Cataphoresis    35 

Hypodermically 36 

on  Mucous  Membranes    : . .     37 

Codeine  in  Abdominal  Surgery 3 

Cold  Abscess 21 

Colic,  Biliary 171,   173 

Gallstone 199 

Hepatic 199 

Colitis  after  Appendectomy   84 

Colles's  Fracture 163 

Colloid  Cancer 1 16,  125 

Colon  Bacillus 92 

Bacillus  Abscesses    23 

Colonic  Flushing  before  Operation 250 

Colorless  Iodine    215 

Combined  Anesthetics   37 

Complications,  Postoperative   345 

Condurango  for  Cancer 1 18 

Condyloma     138 

Confinement,   H-M-C   in    ._.  .  „  ,^^.,-^r 57 

Conjunctivitis    138 

Constipation,  Mechanical   139 

Contractures  of  Fingers    161 

Convalescence    139 

Iron  Tonic  in   139 

Nux  Vomica  in   140 

Tonic  for 140 

Cornea,   Ulcer  of   141 

Corns 142 

Corrosive   Sublimate   Solutions    97 

Covering  the   Wound    250 

Coxalgia   208 


378  INDEX 

Coxarthrocace 208 

Coxitis 208 

Cradle,   Surgical    143 

Cresol  for  Antisepsis  72 

Cryptorchidism    308 

Cure   of   Gallstones    172 

Cystadenoma  146 

Cystalgia 145 

Cystatrophia 146 

Cystitis 99 

Acute - 143 

Chronic 144,  347 

Gonorrheal 145 

Postoperative   345 

Cystobubonocele    146 

Cystocarcinoma 146 

Cystocele  (Prolapse  o%f  Bladder)    100 

Cysts   146 

Adenomatous  146 

Carcinomatous 146 

Dermoid   146 

Echinococcal 146 

Muellerian 147 

Retention    147 

Wolffian 147 

Cyanosis  of  Child  in  H-M-C  Deliveries   57 

D 

Dactylitis 147 

Dactylolysis 147 

Debility,  Sexual 283 

Decolorized  Iodine   215 

Deformities,  Cicatricial    137 

of  Spine    290 

Delirium  of  Erysipelas   354 

of  Hunger 350 

of  lodoform  350 

Postoperative 349 

Depilatory 148 

Dermoid  Cysts   146 

Diabetic   Gangrene    1 74,  175 

Diaphragm,    Hernia    through    203 

Diphtheria,  Germ  of 93 

Diplococcus  Albicans  Tardissimus  94 

Intercellularis  Meningitidis 94 

Pyogenes  Ureae   94 

Ureae  Trifoliatus 94 

Displaced  Kidney 224,  227 

Dobell's  Solution 72 

Drainage  of  Ankle  70 

Drop-Method   of   Ether   Administration 37 


INDEX  379 

Dropsy,  Abdominal   89 

Dusting  Powder   72 

Powder,  Resorcin  as   149 

Powder  for  Ulcer  of  Leg  327 

Dysentery,  Amebic 34 

Dyspepsia,  Surgical  Cure  of   149 

Dysphagia 149 

E 

Eberth's   Bacillus    94 

Echinococcus  Cysts    146 

Echyaditis 80 

Ecchymosis 98 

Ectodermic  Tumors  312 

Eczema  .» 149 

Diet  in   151 

Surgeon's    152 

Elaterin  in  Abdominal   Surgery    3 

Embolism,  Pulmonary,  after  Operation 249 

Emergency  Chloroform  Dropper   40 

Chloroform  Mask  .  — 42 

Surgery,  H-M-C  in   58 

Emesis  after  Anesthesia   66 

Emissions,    Seminal    281 

Empyema 152 

Encephaloid  Cancer 125 

Endarteritis 86 

Enema,    Nutrient    153 

Ox-Gall    . . . : 247 

Enuresis   from    Adenoids    32 

Nocturna ' 154 

Epididymitis 155 

Epilepsy,   Traumatic    155 

Epistaxis 156 

Epithelial  Cancer   116 

Epithelioma    125 

Epityphlitis    80 

Ergotin  for  Tympanites   322 

Erysipelas 156 

Convalescence  from   156 

Facial 157 

Local  Applications  in   157 

Postoperative 351 

Treatment  of  Facial    158 

Eserine  Salicylate  after  Abdominal  Section   13 

Esophagus,    Foreign   Body  in 158 

Ether  by  Drop-Method 37 

Ethyl  Chloride  Anesthesia   38 

How  to   Give    45 

Exophthalmic  Goiter 182 

^Operation  for    184 


380  INDEX 

Exostoses    1 10 

Exstrophy  of  Bladder 99 

Eye  Lid,  Inflammation  of 104 

F 

Facial  Erysipelas 157 

Treatment  of 157 

Fear,   Shock  from    365 

Fecal  Abscess   21 

Disorders 158 

Fistula 158 

Impaction 159 

Feet,  Disorders  of  . 159 

Sweating 159 

Swollen   159 

Tender 160 

Felon 161 

Femur,  Fracture  of   167 

Fetal  Rickets 28 

Fever  of  Appendicitis   81 

with  Gallstones 170 

after  Operation 245 

Putrefactive    278 

Streptococcic    297 

Surgical 161 

Syphilitic 307 

Fingers,   Contractures  of   161 

Fracture  of 163 

Inflammation  of   147 

Fissure  of  Anus 76,  197 

of  Rectum   • 197 

Fistula  of  Anus 78 

Fecal  158 

Treatment  after  Operation 162 

Fiat-Foot 159 

Floating  Kidney    224,  227 

Fore  Arm,  Fracture  of 164 

Fowler  Position  in  Peritonitis  6 

Fractures 163 

Acromion    163 

Colles's   163 

Finger . .  163 

Fore  Arm 164 

Humerus 165 

Leg 165 

Olecranon 166 

Operative  Treatment  of .  168 

Patella 166 

Superiosteal — 168 

Thigh 167 

Ulna 167 


INDEX  381 
\ 

Fractures — Vomer 333 

Furunculous  Acne  of  Neck 242 

G 

Gall  Bladder,  Inflammation  of 132 

Gallstone  Colic  199 

Gallstones 169 

Fever  with 170 

Pain  of 171 

Secondary  Operations 170 

Sodium  Oleate  for 173 

Ganglion,  Cure  of   173 

of  Wrist   368 

Gangrene    1 74 

Carbolic  Acid   174 

Diabetic 1 74,  175 

Internal  Medication 175 

Gastric  Hemorrhage   176,  177 

Lavage 8 

Pain 171 

Ulcer  176 

Ulcer,  Removal  of  177 

Gauze,   Care  of   1 78 

Gelatin  for  Gastric  Hemorrhage 176 

Genital  Tuberculosis   313 

Genitourinary  Suppuration ' 1 79 

Genu  Valgum   no 

Varum .' no 

Germicides 71 

Glands,   Inflammation  of 30 

Enlarged,  Iodine  for  30 

Inflammation  of  Inguinal   113 

Scrofulous 31 

Suppuration  of 299 

Gleet   179 

Glonoin  after  Operation 246 

Glossitis 181 

Gloves,  Rubber 255 

Rubber,  Substitute  for   277 

Goiter   181 

Exophthalmic 182 

Gonococcal  Synovitis 302 

Gonococcus    94 

Gonorrhea 185 

Chronic    (Gleet)    179 

of  Joints 220 

Lingering    188 

Gout    87 

Graves's  Disease  . .                                                                          .  182 


382  INDEX 


H 

Hair,  Removal  of : .  148 

Hand  Cleanness,   Maintenance  of 250 

Hands,  Cleaning  Quickly 191 

Diseases  of 189 

Eczema  of   190 

Neuroma  of 190 

Phenol  for   190 

Phlegmon  of   189 

Turpentine   for    191 

Preparation  of,  for  Operation 252 

Harrington's  Solutions 73 

Head  of  Radius,  Fracture  of 164 

Heart  Failure  in  H-M-C  Anesthesia  55 

Heel,  Painful . 259 

Hematemesis 177,  192 

Hemophilia 193 

Joint  Lesions  in  194 

Hemoptysis 194 

Hemorrhage  195 

Internal 195 

Lung  194 

Stomach  176,  177,  192 

Urethral    328 

Hemorrhoids 196 

Aesculin  for 197 

and  Fissure   197 

Inflamed •. 198 

Injection  of  . . , 199 

Nitric  Acid  for » 199 

Hepatic  Colic 199 

Hepatitis 201 

Acute  (Tropical)  24 

Hernia,   Appendicitis  in   83 

of  Bladder  99 

Cerebral    203 

of  Childhood 203 

Diaphragmatic 203 

Inguinal 204 

Injection  of   205 

Internal 14 

Reduction  of 206 

Strangulated 207 

Herniotomy  under  Local  Anesthesia  205 

Hiccough  after  Operation 207,  246 

Hip  Joint  Disease 208 

Hodgkin's  Disease 235 

Humerus,  Fracture  of 165 

Hunger,  Delirium  of   * 350 

Hydrocele 208 

Injection~of 208 


INDEX  383 

Hydrogen  Dioxide    209 

Hydrops  Abdominis 89 

Hypertrophy  of  Bones no 

of  Prostate 268 

Hypodermoclysis  in  Acetonuria   27 

Caution  in 209 

in  Peritonitis 10 

Hyoscine-Morphine-Cactin  (H-M-C)  Anesthesia 47 

Advantages  of   62 

Anuria  in  55 

Disadvantages  of 62 

Dosage  of  52 

Effects  of   60 

Emergency  Surgery,  Use  in    58 

in  Labor  57 

Mottled  Skin    from    54 

in  Peritonitis  7 

Precautions  in  Using 59 

Respiratory  Failure   from   54 

Safety  of  53 

Shock  in 56 

Statistics   of 58 

Hyoscyamine  for  Prostatorrhea 268 

I 

Ichthyol  for  Sprains   293 

Icterus 218 

from  Sepsis    357 

Ileocecal  Tuberculosis  314 

Ileus  Paralyticus 12 

Impaction,    Fecal    159 

Imperforate  Anus ..     78 

Impotence  of  Joints    222 

Incised  Wounds    340 

Incontinence  of  Urine  209 

Indigestion  after  Operation   -. 246 

Infantile  Hernia 203 

Syphilis 306 

Infections,  Local 210 

Influenza,   Bacillus  of   vrrrrrrTT 93 

of  Knee   228 

Ingrowing  Nails 212 

Inguinal  Glands,  Inflammation  of 113 

Hernia  of  Children   204 

Injection   of  Hemorrhoids    199 

of  Hernia  205 

of  Hydrocele    208 

of  Joints   with   lodof orm    217 

Treatment  of  Tetanus    308 

Injury,  Suggestion  after  \  . ._ 91 

Insanity  afterJHead^Injury^ 27 


384  INDEX 

Insanity — Following  Operation 355 

and  Prolapsed  Kidney   225 

Instruments,  Sterilization  of 295 

Internal  Hemorrhage 195 

Intestinal  Indigestion  after  Operation 246 

Obstruction,  Treatment  after  Operation   213 

Thrombosis    15 

Intraarticular  Hemorrhage 194 

Intraperitoneal  Tuberculosis 315 

Intussusception    214 

Inversion  of  Bladder 99 

Iodides  for  Aneurism   68 

Iodine  Catgut 127 

Colorless 215 

for  Enlarged  Glands  30 

for  Goiter 185 

lodof orm •. 216 

Absorption  of 216 

for  Cirrhosis  of  Liver   : 232 

Delirium 350 

Injections   217 

Wax  Filling 217 

Iron  in  Convalescence 139 

Irrigation  of  Stomach  8 

Irritation  from  Urine 331 

J 

Jaundice 218 

from  Infection 357 

Postoperative  356 

Joint,.  Charcot's 87 

Inflammation 221 

Lesions  in  Hemophilia  194 

Joints,  Acute  Infections  of  218 

Ankylosis  of 219 

Gonorrhea  of 220 

Hemorrhage  into 194 

Inflammation  of 87,  300 

lodoform  Injections  in  217 

Secondary  Impotence  of 222 

Syphilitic 87 

Tuberculosis  of 222 

K 

Kidney,  Diseases  of  223 

Displaced  224,  227 

"  Insanity  and  Prolapse  225 

Stone  in  the 223 

\  Treatment  after  Operation  on 224 

Tuberculosis  of  ,,,,,,.....  T .  T .,.,.,.,.,.,,,,.. 226 


INDEX  385 

Klebs-Loeffler   Bacillus   93 

Knee,  Influenza  of 228 

Knives,  Sterilization  of  73 

Koch's  Bacillus 94 

L 

Labor,  H-M-C  in   57 

Lacerated  Wounds 342 

La   Grippe,   Bacillus  of 93 

Lateral  Curvature  of  Spine  280 

Leukemia  229 

Leg,  Fractures  of 165 

Ulcers  of 325 

Leptothrix  Puerperale   93 

Lid  Abscesses   .N 230 

Lipomatous  Cancer   125 

Liver,  Abscess  of  231 

Abscess,  Tropical  24 

Acute  Yellow  Atrophy  t>f 357 

Cirrhosis  of   231 

|    Diseases  of 231 

1    Inflammation  of   201 

Talma  Operation  on  307 

Local  Anesthesia 35 

for  Herniotomy    : 205 

in  Rectal  Surgery    271 

Applications  in  Erysipelas   . .- 157 

Infections    210 

Lockjaw    308 

Loosened  Kidney 224,  227 

Lumbar  Anesthesia   63 

Lumbomyalgia 232 

Lung  Complications  after  Abdominal  Section 232 

it   Diseases  of 232 

T  Hemorrhage   from    194 

K  Surgery  of  the 233 

Lupus   233 

Lustgarten's  Bacillus   93 

Lymphadenitis 234 

In  Tuberculous 316 

Lymphosarcoma    235 

M 

Macewen's  Chromic    Catgut   236 

Malignant  Eczema 258 

Pustule    71,  236 

Mammary  Abscess 22 

Marmorek's   Serum   Useful    354 

Marsden's  Paste  for  Cancer   1 19 

Martin's   Bandage    237 


386  INDEX 

Mastitis 1 1 1 

Masturbation  from  Adenoids   32 

Mediastinum,   Cancer  of 1 18 

Mercury,  Bockharts'  Blood-Serum 106 

Mesodermic  Tumors 312 

Methylene   Blue  for  Cancer 119 

Micrococcus  Cereus  Albus  94 

Cereus  Flavus 94 

Gonorrheae 94 

Osteomyelitidis 94 

Moles  and  Cancer 238 

Removal  of   238 

Mouth,  Ulcers  of 121,  239,  327 

Mucous  Membranes,  Cocaine  on 37 

Muellerian  Cysts  .' 147 

Murphy's  Substitute  for  Rubber  Gloves 277 

Muscular  Strain   — 232 

Myositis  of  Abdominal  Wall   , 240 

Myxedema,  Postoperative 240 

N 

Nails,  Ingrowing 212 

Neck,   Furunculosis  of   242 

Necrosis  of  Bone   125 

Neisser's  Micrococcus   94 

Nervous  Collapse 365 

Neuralgia,  Trifacial 312 

Neurasthenia,  Sexual , 284 

Newly-born,  Artificial  Respiration  in  Case  of 87 

Nicolaier,   Bacillus  of -. 94 

Nipple,   Paget's  Disease  of 258 

Nitric  Acid  for  Piles    199 

Nocturnal  Enuresis 154 

Noma 122 

Bacillus  of 93 

Nonmalignant  Stricture  of  Rectum 273 

Nonsurgical  Cure  of  Gallstones  172 

Nose  Bleed 156,  242 

Nux  Vpmica  in  Convalescence    146 


O 

Obstruction  of  Bowels   12 

of  Bowel  from  Imperfect  Operation 16 

of  Bowel  from  Packing 17 

Oidium  Albicans 94 

Ointment,   Gallic  Acid   169 

Olecranon,   Fracture  of   166 

Operation,  Anuria  after  244 

Appetite  after,  to    Increase 249 

Backache  after   244 


INDEX  387 

Operation,   Black  Vomit  after 245 

Complications  following   345 

Delirium    following    349 

Erysipelas  after 351 

Fever  after 245 

Glonoin  after 249 

for  Bright's  Disease   112 

for  Fractures 168 

for   Goiter    184 

Hiccough  after 207,  246 

Icterus  from 356 

Insanity  after    355 

Jaundice  after 356 

Management  after   243 

Pain  after  229,  359 

Phlebitis  after  248 

Position  after 247 

Preparation  before  Scrubbing   252 

of  Hands  252 

Preparations  for 250 

Pulmonary  Embolism  after 360 

Purgation  before 254 

Shock  after 360 

Solutions  for 254 

Table,  Impromptu 243 

Thirst  after   366 

for  Streptococcic  Fever 297 

Vomiting  after   250,  366 

Operations,  Imperfect 1 1 1 

Opium  in  Abdominal  Surgery 4 

in  Peritonitis  5 

Opsonic  Treatment  in  Surgery 256 

Osteomalacia  257 

Osteomyelitis    218,  257 

Germ  of 94 

Oxide  of  Silver  for  Hematemesis   193 

Ozena   258 

Paget's  Disease 258 

P 

Pain  258 

after  Operation 259 

Chlorophenol  for 258 

Gastric 171 

of  Abscesses 22 

of  Appendicitis  81 

of  Gallstones 171,  173 

of  Gastric  Ulcer 177 

of  Peritonitis  262 

Postoperative 259,  359 

Painful  Heel 259 


388  INDEX 

Painful — Swallowing 149 

Panarthritis 70 

Pancreatitis 259 

Pans,  Sterilization  of 294 

Paralysis  of  Bladder  100 

Parotitis,  Syphilitic 305 

Pasteur's  Vibrion  Septique    93 

Patella,  Fracture  of  . 1 66 

Penis,   Inflammation  of  Glans   95 

Pericarditis     261 

Periostitis,  Chronic 262 

Peritonitis 262 

from  Appendicitis 84 

Fowler's  Position  for 6 

H-M-C  in 7 

Hypodermoclysis  for 10 

after  Operation 4 

Irrigation  for 9 

Localized 9 

Pain  in  262 

Suppurative    84 

Tubercular    263,  317 

Perityphlitis   (See   Appendicitis) 

Peroxide  of  Hydrogen 209 

Phagadena  (Tropical) 35,   131 

Phenol  for  Antisepsis 72 

as  Local  Anesthetic 65 

for  Buboes  112 

for  Hands 190 

Gangrene    174 

Salicylate  for  Cystitis 145 

Phlebitis   264 

after  Abdominal  Section 1 1 

following    Operation    248 

Phlegmon  of  Hands 189 

Phthisis,   Surgery  of   319 

Piles 196 

Aesculin  for 197 

and  Fissure 197 

Inflamed 198 

Injection  of 199 

Nitric  Acid  for 199 

Treatment  after  Removal 198 

Pilocarpine   for  Acetonuria    27 

in  Syphilis   306 

Pleuritis 265 

Suppurative    152 

Pneumonia,  Bacillus  of 93 

Polyps  of  Anus 79 

Position  after  Operation 247 

Postoperative  Anuria   74,  244 

Complications 345 


INDEX  389 

Postoperative   Cystitis      345 

Delirium 349 

Erysipelas 351 

Hiccough 246 

Ileus 4 

i    Indigestion  246 

;    Insanity 355 

Jaundice 356 

Obstruction  of  Bowels    18 

Pain 359 

Paralysis 260 

Peritonitis 4 

Phlebitis n,  248 

Pulmonary  Embolism    360 

Shock 1' 285,  360 

Thirst    366 

Treatment  in   Appendicitis    85 

of  Bladder  Operation  101 

of   Fistula 162 

[    of  Hemorrhoids 198 

of  Intestinal   Obstruction    213 

in  Kidney  Lesions 224 

in  Stomach  Operations 296 

Vomiting    245,  250,  366 

Pott's  Disease  292 

Poultices 266 

Charcoal 266 

Soap 266 

Precautions  in  H-M-C  Anesthesia  59 

Pregnancy,  Appendicitis  in   83 

Preparation  of  Hands  for  Operation   252 

for  Operation   250 

of  Skin  for  Operation    251 

Preservative  Fluid,  Wickersheimer's   334 

Prevention   of  Adhesions    i 

of  Bedsores 96 

of  Boils 108 

of  Cancer 120 

of  Chordee     136 

of  Shock , , 361 

Proctitis 267 

Prolapse  of  Anus 79 

of  Bladder   100 

of  Rectum 271,  272 

Prolapsed  Kidney  and  Insanity 225 

Prostate,  Hypertrophy  of 268 

Prostatorrhea     268 

Prostatectomy,   Indications  for   267 

Protruding  Piles   198 

Pruritus   Ani    79,  268 

Treatment  of 269 

Psoas  Abscess  .  22 


390  INDEX 

Pulmonary  Embolism   360 

following    Operation 249 

Punctured  Wounds   344 

Purgation   before   Operation    , 254 

Pus  in   Urine    271 

Pustule,    Malignant    71,  236 

Putrefactive  Fever   278 

Pyemia    271,  282 

Pyloric  Stenosis .- 269 

Pyothorax 152 

Q 

Quarter  Evil   71 

R 

Radium  for  Cancer 121 

Radius,  Fracture  of  Head 164 

Rectum,   Cancer  of   274 

Diseases  of    — 1 271 

Examination  of 271 

Fissure  of 197 

Fistula  of 78 

Inflammation  of  267 

Local  Anesthesia  in  Surgery  of 271 

Prolapse   of    271,  272 

Stricture  of   273 

Resorcin  as  Dusting  Powder   149 

Retention   Cysts    147 

Retrorectal  Abscess 273 

Respiration,  Artificial 87 

in  Adults   88 

Difficult,  in  Newly-born,   after  H-M-C   57 

Respiratory   Failure    54,  275 

in  Chloroform  Narcosis 44 

in  H-M-C  Anesthesia 54 

Rheumatism 87 

Ribs,  Cervical 128 

Rickets,  Fetal   28 

Ricord's   Formula   for   Gleet    180 

Rodent  Ulcer 276 

Rubber    Gloves    255 

Gloves,   Murphy's   Substitute    277 

Rupture ". 202 

of  Aneurism 69 

Ruptures  of  Childhood  203 

S 

Saccharomyces  Albicans   94 

Sapremia   ". 278 

Saprogenic  Bacteria 94 


INDEX  391 

Saprophytic^Bacteria  95 

Sarcoma   279 

Scalds    279 

Scars 279 

Schimmelbusch's  Bacillus 93 

Scirrhus 125 

Scoliosis 280 

Scopolamine  vs.  Hyoscine 47 

Scrofulous   Glands    31 

Secondary  Impotence  of  Joints   222 

Operations  for  Gallstones 1 70 

Seminal  Emissions  281 

Vesicles,  Inflammation  of , _ 333 

Vesicles,  Tuberculosis  of   .v 281 

Senile  Gangrene,  bacillus  of 93 

Sepsis 282 

Headache  of 282 

Septicemia   282,  297 

Septicopyemia    282 

Septic   Jaundice    357 

Sequestrum 283 

Sexual  Debility 283 

Depressant  283 

Disorders •. 283 

Irritation 284 

Neurasthenia   284 

Shock 285 

Due  to  Fear 365 

from  Anesthesia   364 

in  H-M-C  Anesthesia  56 

Postoperative 285,  360 

Prevention  of 361 

Treatment  of 362 

with  Abdominal  Pain 286 

Skin,  Necrosis  of 96 

Preparation  for  Operation 251 

Silver  Oxide  for  Hematemesis   193 

Skull,  Wounds  of 287 

Smegma  Bacillus   94 

Snake  Bites  289 

Soap  Poultices 266 

Suppositories    '. 289 

Sodium  Oleate  for  Gallstones 173 

Solution,  Antiseptic   72 

Dobell's 72 

Harrington's 73 

Solutions  for  Operation   254 

Sparteine  for  Anuria 55 

Spermatocele    290 

Spina  Bifida v .   290 

Spinal  Abscess 23 

Injection  for  Tetanus 308 


392  INDEX 

Spine,  Curvature  of 280 

Deformities  of 290 

Splanchnoptosis 291 

Spleen,  Abscess  of 291 

Splints,  Silicate  of  Sodium   287 

Spondylitis   292 

Sprains    292 

of  Ankle 70 

of  Back  91 

Staphylococcal  Synovitis 301 

Staphylococcus  Epidermidis  Albus 95 

Pyogenes  Albus : 95 

Aureus    95 

Citreus 95 

Statistics  of  H-M-C  Anesthesia 58 

Status  Lymphaticus  292 

Stenosis  of  Pylorus 269 

Sterilization  of  Instruments  295 

of  Knives  73 

of  Pans 294 

in  Surgery .' 294 

Stings  of  Bees 97 

Stitch  Abscesses   23 

Stomach,    Cancer   of    • —  1 18,  296 

Diseases  of 296 

Hemorrhage  from 176,  177^  192 

Irrigation  of 8 

Operations,  Aftertreatment  of 296 

Ulcer  of 176 

Stomatitis,  Ulcerative 121 

Stone  and  Enlarged  Prostate 268 

in  Kidney 223 

Strain  of  Muscles   232 

Strangulated  Hernia 207 

Streptococcal  Synovitis 301 

Streptococcic  Fever 297 

Streptococcus  Pyogenes 95 

Stricture    298 

of  Rectum 273 

Strychnine  for  Respiratory  Failure   275 

in  Strangulated  Hernia 207 

Styes 104,  299 

Subperiosteal  Fracture 168 

Suppositories,  Soap 289 

Suppuration '. 20,  299 

Calcium  Sulphide  in   300 

Deep  Glandular  299 

Genitourinary    179 

in  Carbuncle 123 

Soap  Poultice  for 266 

Tubercular 25 

Suppurative  Peritonitis   84 


INDEX  393 

Suppurative  Synovitis    219 

Surgeon's  Eczema 152 

Surgery,  Bacteria  of   92 

H-M-C  Anesthesia  in   58 

of  Lung 233 

of  Pulmonary  Tuberculosis    319 

Rubber  Gloves  in   255 

Sterilization  in 294 

Surgical  Autosuggestion 91 

Cradle 143 

Cure  of  Dyspepsia 149 

Fevers   161 

Tuberculosis 312 

Suture  Material 302 

Suturing  Wounds  337 

Swallowing,  Painful 149 

Sweating  Feet   160 

Swollen  Feet   160 

Sympathetic   Buboes    113 

Synovitis 219,  300 

Acute 302 

Ankylosing  222 

Gonococcal .' 302 

Plastic 222 

Staphylococcic  301 

Streptococcic 301 

Syphilis 304 

Bacillus  of 93 

of  Childhood  306 

Primary    128 

Treatment  by  Blood-serum  Mercury 106 

Syphilitic  Fever 307 

Joints 87 

Parotitis 305 

Ulcers 305,  327 

T 

Table,  Impromptu  Operation  243 

Talma  Operation  307 

Tender  Feet 160 

Tendon  Sheath  Abscess 24 

Teratoid  Tumors  312 

Teratoma  321 

Testicle,  Tuberculous  318 

Undescended  308 

Tetanus 308 

Bacillus  of 94 

Thecal  Abscess  24 

Thecitis 24 

Thigh,  Fracture  of  167 

Thiosinamin  for  Stricture 298 


394  INDEX 

Thirst,  Postoperative  366 

Thrombosis  of  Intestinal  Vessels  15 

Thymol  as  an  Antiseptic 74 

Toe,  Inflammation  of 147 

Nails,  Ingrowing 212 

Tongue  Forceps  Condemned- 309 

Inflammation  of  181 

Tooth  Paste 309 

Torticollis 310 

Tracheotomy   310 

Trendelenburg's  Position,  a  Precaution   311 

Tricomi,  Bacillus  of 93 

Transfusion  of  Blood 105,  310 

Traumatic  Autosuggestion 91 

Epilepsy   155 

Tropacocaine  for  Anesthesia 63 

Tropical  Abscess 24 

Trypsin  in  Cancer 121 

Tubercular  Abscess 25 

Peritonitis    263 

Tuberculosis,  Abscesses  in 25 

Bacilllus   of 94 

from  Decayed  Teeth 312 

Genital    313 

Iliocecal 314 

Intraperitoneal 315 

of  Bladder 102 

of  Glands  31 

of  Joints 222 

of  Kidney  i 226 

of  Seminal  Vesicles  ., 281 

of  Testicle  318 

of  Urethra 329 

Pulmonary,  Surgery  of  319 

Surgical 312 

Tuberculous  Adenitis 30 

Glands 31 

Lymphadenitis 234,  316 

Peritonitis 3*7 

Tumors 320 

Abdominal i 

Actinomycotic 28 

Adenoma 33 

Angioma 69 

Appendical  83 

Bladder 102 

Condyloma - 138 

Cystic 146 

Dermoid  164 

of  Abdomen i 

List  of 321 

Neuroma  of  Hand •^I9° 


INDEX  395 

Turpentine  for  Hands   igi 

Tympanites 321 

Alum  for 322 

Typhlitis — See   Appendicitis. 

Typhoid  and  Cholecystitis  135 

Calcium  Iodide  for  327 

Dusting  Powder  for 327 

Gastric  176 

of  Bladder 103 

Rodent 276 

Spine 322 

Syphilitic  305,  327 

U 

Ulcers    323 

of  Cornea 141 

of  Leg 325 

of  Mouth  121,  239,  327 

Ulna,  Fracture  of 167 

Undescended  Testicle 308 

Urachus,  Cysts  of 330 

Tumors  of  330 

Uranalysis  in  Surgery  27 

Urea,  to  Increase  Amount  of 330 

Uremia   330 

Urethra,  Diseases  of  ' 328 

Foreign  Body  in 328 

Hemorrhage  from 328 

Inflammation  of  329 

Stricture  of    298 

Tuberculosis  of 329 

Urethritis    329 

Chronic 180 

Specific   185 

Urinary  Calculus 223 

Urine,   Incontinence  of   209 

Irritation  from 331 

Pus  in 271 

Uvula,   Inflammation  of .^nr.^^rrr^.T. 137 

V 

Varicocele,  Cure  of  332 

Varicose  Veins 331 

Veins,  Inflammation  of 1 1 

Varicose 331 

Vesiculitis 333 

Tuberculosis  of 281 

Vibrion  Septique  de  Pasteur 93 

Volvulus 14.  333 

Vomer,  Fracture  of  333 


396  INDEX 

Vomit,  Black 98 

Vomiting  after  Anesthesia   66 

I    after  Operation  250 

in  Appendicitis    82 

in  Chloroform  Anesthesia 45 

in  Gastric  Ulcer 177 

Postoperative   366 

W 

Wandering  Kidney 224,  227 

Warts,  Removal  of 333 

Washing  Out  of  Abscesses   26 

Wax  Filling,  lodoform   217 

Welander's  Treatment  of  Buboes   113 

Wetting  the  Bed   154 

Whitlow 161 

Wickersheimer's  Fluid 334 

Wiring  of  Aneurism   67 

Wolffian  Cysts 147 

Wounds 335 

Balsam  of  Peru  for 335 

Contused    344 

Covering 250 

Dry  Heat  for   335 

Incised 340 

Lacerated  342 

of  Arteries    86 

of  Bladder   103 

of  Skull 287 

Punctured 344 

Suturing  of 337 

Treatment  of  Infected 340 

Wrist,   Ganglion  of   368 

Wry  Neck   310 

X 

X-Ray  Burns 369 

for  Arthritis  Deformans   87 

for  Cancer   368 

for  Leukemia    229 

for  Sprained  Ankle 70 

for  Tubercular  Glands   30 

for  Tuberculous  Testicle    318 


Yellow  Atrophy  of  Liver 357 


Alkaloidal  Practice 


A  Practice  of  Medicine  with  Special  Reference  to 
the  Use  of  the  Active  Principles 


By  William  F.  Waugh,  M.  D.  and  Wallace  C.  Abbott,  M.  D. 


Here  is  a  book  which  is  years  in  advance  of  any  other  work  on 
Practice  in  this  country. 

It  deserves  the  careful  consideration  of  the  entire  medical  profession. 
The  days  of  therapeutic  uncertainty  are  passing.  The  demand  of  the 
public  is  for  more  prompt  and  definite  results  in  medicine,  for  relief 
from  the  big,  bitter,  nauseating  dose.  Shotgun  prescriptions  must  go — 
science  demands  it.  To  accomplish  this  the  newer  therapy  so  far  as 
possible  places  in  the  hands  of  the  profession  the  single  remedy,  the 
active  principle. 

The  authors,  Drs.  Waugh  and  Abbott,  are  well  prepared  to  produce 
just  such  a  work.  They  have  had  the  experience  that  counts.  They 
have  been  laboring  for  years  to  make  this  book  the  most  valuable  of 
its  kind  ever  yet  produced,  and  it  stands  as  a  magnificent  monument 
to  their  work,  which  has  been  an  earnest  effort  to  raise  the  standard  of 
medicine  to  a  higher  plane.  And  more  fortunate  than  many  other 
pioneers  in  untilled  fields,  while  still  engaged  in  their  struggles  to 
overcome  prejudice  and  unbelief,  they  see,  in  an  ever -increasing 
measure,  the  accomplishment  of  their  desires  and  the  fruition  of  their 
hopes.  Truth  is  mighty  and  will  prevail. 

Cloth  bound,  over  700  pages.  Price  $5.00  ash  with  order ,  delivery 
prepaid.  With  new  or  renewing  subscription  to  "Clinical  Medicine'' 
$6.00.  After  Jan.  ist,  '08,  combination  price  $6.50.  Money  back  if 
not  satisfied. 


The  Clinic  Publishing  Company 

Ravenswood  Station,  Chicago 


Of  Exceptional  Interest 

The  W-A   Alkaloidal  Therapeutics 

A  Condensed  Text-Book  of  Active-Principle  Therapy 
By  Drs.  Waugh  and  Abbott 


This  book  contains  not  only  a  condensed  resume  of  all  the  available 
literature  on  the  subject  of  the  Active  Principles,  but  in  addition,  the 
personal  experience  of  the  writers.  From  cover  to  cover  throughout 
the  entire  238  chapters  and  405  pages,  there  is  nothing  but  solid  meat. 
There  are  no  useless  words  and  no  padding. 

The  remedies  are  considered  in  alphabetical  order  so  that  any  prepa- 
ration may  be  quickly  found.  A  complete  therapeutic  cross  index 
makes  everything  in  the  volume  very  accessible,  and  the  book  is  inter- 
leaved with  blank  pages  for  the  doctor's  "commentary." 

Notwithstanding  the  name,  it  is  more  than  "alkaloidal."  It  deals 
not  only  with  the  active  principles — alkaloids,  glucosides,  resinoids  and 
some  desirable  concentrations  but  with  many  of  the  metallic  drugs  and 
salts  and  other  dependable  remedies  in  daily  use.  While  this  book  is 
distinctively  American  the  authors  have  drawn  upon  the  foreign  Dosi- 
metric  and  other  European  literature  as  well  as  the  practice  of 
Americans  of  all  schools  and  methods.  One  of  the  most  valuable 
sources  of  information  has  been  "Clinical  Medicine"  itself  and  the 
extensive  correspondence  which  the  authors  have  carried  on  with  many 
thousands  of  physicians,  upon  subjects  of  practical  importance.  The 
result  is  a  book  whose  primary  purpose  is  that  of  helpfulness. 

Doctor,  your  library  is  not  complete  without  this  volume.  It  is  a 
veritable  store-house  of  ideas  that  you  can  convert  daily  into  "coin  of 
the  realm." 

The  price  of  the  book  in  handsome  cloth  binding  is  only  $2.50,  cash 
•with  order,  all  delivery  charges  prepaid.  With  new  or  renewing 
subscription  to  "Clinical  Medicine"  for  one  year,  $3.50.  After  Jan.  ist, 
'08,  combination  price  $4.00. 

Send  your  order  now.  If  you  are  not  entirely  satisfied  return  the  book 
in  good  condition  and  we  will  return  your  money. 

Find  inclosed   money   order    for  Permit  me  to  congratulate  you  on 

$2.50  amount  I  am  in  your  debt  for  fv._  •w-  A  AiicnioiHal  Thpranpntirs 
one  copy  of  your  W-A  Alkaloidal 

Therapeutics.  This  may  pay  you  It  is  an  admirable  work  and  I  am 
for  the  book,  but  for  the  pleasure  sure  will  be  valued  highly  by  those 
fngd  orthe'book6  feanTniythTnk  members  of  the  medical  profession 
you.  DR.  J.  L.  CARNAHAN.  who  desire  to  practice  medicine 

Kansas  City,  Mo.  accurately    and    scientifically.      It 

Your  W-A  Alkaloidal  Therapeutics  should  certainly  reduce  the  number 
r^e^anbd0ConsSlufionbralave  «*  nihilists  as  regards  the  therapeu- 
recommended  it  to  my  friends.  tical  use  of  remedies. 

DR.  A.  A.  NEEPE.  JAMES  THOMPSON,  M.D. 

Lookout  Mountain,  Tenn.  Kansas  City,  Mo. 

The  Clinic  Publishing  Company 

Ravenswood  Station,  Chicago 


Ten  Years  of  American  Alkalometry 

Four  Great  Books  for  your  Library 


AN  INEXHAUSTIBLE  MINE  OF  HELPFULNESS 


Beautifully  Bound.     Over  Three  Thousand  Pages 

The  four  volumes  of  American  Alkalomelry,  edited  by  Drs.  W.  C. 
Abbott  and  W.  F.  Waugh,  contain  an  epitome  of  the  teachings  of  The 
Alkaloidal  Clinic  for  the  past  ten  years.  This  record  embraces  not 
only  the  clinical  observations  of  the  editors  and  their  immediate  asso- 
ciates, but  of  thousands  of  physicians  in  the  use  of  alkaloidal  prepara- 
tions, their  advantages  and  indications.  Herein  are  described  the  ex- 
periences of  the  real  working  doctor  with  every-day  maladies — the 
difficulties  that  beset  him  in  his  daily  work,  the  means  he  has  found 
effectual  in  surmounting  them.  As  a  therapeutic  guide  these  volumes 
are  of  inestimable  value.  Each  volume  contains  over  800  pages  alpha- 
betically arranged  with  complete  index  classified  by  subjects  and 
authors. 

DON'T  THINK  FOR  A  MINUTE 

that  this  is  material  out  of  date.  It  is  nothing  of  the  kind.  It  is  v!ta 
truth  of  yesterday,  today  and  forever,  arranged  to  be  found  and  used, 
and  you  should  have  it.  If  you  would  have  the  latest  and  the  best  here 
it  is  ready  at  your  hand. 

Ammran  AlkalnmptTV~active~principle  Practice— heralds  a 
AlLierildll  AlHdlUlllCiryrevolutioil  in  therapeutics.  Active- 
principle  Therapy  has  surely  come  to  stay.  There  are  no  books  more 
intensely  interesting  and  valuable  for  the  progressive  practician  than 
the  four  volumes  of  American  Alkalometry  above  described. 

ft  f far  The  price  of  each  book,  beautifully  bound,  is  $2.00; 

1/llCl  either  voiume  with  the  CLINIC  for  one  year,  $3.25, 
after  January  ist,  1908,  $3.75?  the  complete  set,  four  volumes,  $7.00, 
cash  with  order,  or  $2.00  down  and  $2.00  a  month  for  three  months. 
The  complete  set  with  the  CLINIC  one  year,  $8.00,  after  January  ist, 
1908,  $8.50,  cash  with  order,  delivery  prepaid.  Make  your  order 
for  what  you  want  and  the  way  you  want  it.  We  are  not  afraid  to 
trust  you,  don't  be  afraid  to  trust  us. 

If  yon  are  not  satisfied  on  receipt,  return  the  books  and  we  will  refund  your 
money.  Every  Clinic  reader  would  profit  by,  and  should  have,  a  complete  set  of 
these  books. 

THE  CLINIC  PUBLISHING  COMPANY 

Ravenswood  Station,  CHICAGO 


Shaller's 
Guide  to  Alkaloidal  Medication 


This  book  is  indispensable  to  every  physician  interested  in  alkaloidal 
medication.  It  contains  over  300  pages  of  applied  and  proven  thera- 
peutics, with  an  additional  100  pages  devoted  to  an  exhaustive  clinical 
index.  It  is  written  in  Dr.  Shaller's  inimitable  style,  embodying  his 
personal  research  and  experience,  with  that  of  many  others.  There 
are  45  chapters  covering  the  application,  therapeutics  and  dosage  of 
the  principal  alkaloids. 

"A  LIBRARY  IN  ITSELF." 

Shaller's  Guide  received.  It's  weight  in  gold  would  not  pay  for  what 
I  have  already  learned.  My  library  consists  of  twenty-five  or  thirty 
volumes,  and  honestly,  Shallers  Guide  takes  the  place  of  most  of  them 
when  it  comes  to  treatment.  DR.  R.  S.  ROLAND. 

Paris,  Tex. 

"INDEX  ALONE  WORTH  THE  PRICE." 

I  cannot  <q  eak  highly  enough  of  Shaller's  Guide.     The  Clinical  Index 
alone  is  worth  the  price.     Shaller's  Guide,  the  W-A  Alkaloidal  Therapeutics, 
the  New  Practice  and  the  Clinic  are  on  my  desk  always.     I  appreciate  and 
use  them  more  than  any  medical  literature  I  have. 
Chicago,  I1L  '      DR.  C.  M.  CLAY. 

"PRACTICAL." 

I  received  Shaller's  Guide  to  Alkaloidal  Medication  and  have  perused 
it  with  interest.  I  must  say  that  I  am  more  impressed  with  it  than  any 
work  which  I  have  read  in  a  long  time.  It  is  PRACTICAL  and  will  be  a 
help  to  the  general  practitioner  who  desires  to  become  acquainted  with  the 
methods  it  teaches.  „ 

Winsboro,  Tex. ,  M.  B.  PALLARD.  M.  D. 

"JUST  THE  THING." 

I  am  well  pleased  with  and  much  interested  in  the  book.  It  is  brief 
and  to  the  point.  Just  the  thing  for  the  busy  physician. 

Etna,  111.  DR.  C.  A.  STRICKLER. 

"WOULDN'T  BE  WITHOUT  IT." 

I  would  not  take  $10.00  for  my  Shaller's  Guide  if  I  couldn't  get 
another. 

Decatur,  I1L  DR.  D.  C.  BAYLY. 

$1.00  POSTPAID.  Order  today,  and  if  on  receipt  and  careful  reading 
it  doesn't  prove  to  be  as  meaty  a  little  book  as  you  ever  saw,  send  it 
back  and  we'll  refund  your  mon^y — postage  too.  You  may  be  one  of 
the  favored  thousands  who  have  enjoyed  the  first  edition  for  several 
years;  if  so  you  know  you  want  this.  With  new  or  renewing  subscrip- 
tion to  The  American  Journal  of  Clinical  Medicine  $2.25.  After  Jan. 
ist,  '08,  combination  price,  $2.50. 

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The 

Every-Day  Diseases 
of  Children 

And  Their  Proper  Treatment 

By 
George  H.  Candler,  M.  D. 

Chicago,  111. 

This  little  book  contains  nothing 
of  theory  but  is  full  of  proven  facts 
and  hints  and  just  that  information 
which  we  all  so  often  need  and  so 
rarely  find.  Those  who  have  read 
Dr.  Candler's  articles  in  Ihe  Amer- 
ican Journal  of  Clinical  Medicine, 
especially  his  series  on  Infectious  Dis- 
eases of  Childhood,  will  be  glad  to 
obtain  this  new  book,  which  com- 
prises about  400  pages. 

Price  $1.00. 
Terms:  Cash  with  order,  delivery  charges  prepaid. 

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CHICAGO 


SAVE  THE  BABIES 

In  justice  to  yourself,  Doctor,  and  to  your  little  patients 
of  tender  age,  you  should  read  Dr.  W.  F.  Radue's  new 
book  on  the  treatment  of 

THE  DISEASES  OF  CHILDREN 

The  teachings  of  this  little  work  are  drawn  from  the  per- 
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medicaments. 

It  is  of  convenient  size,  165  pages,  and  contains  chapters 
on  the  Clinical  Examination  of  Children,  Hygienic  Points,  the 
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Charts,  a  complete  Resume  of  Children's  Diseases  and  their 
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tain Drugs,  a  Detailed  Alphabetical  Table  of  Diseases  with 
the  Drugs  Used  and  a  Table  of  Remedies  and  their  Doses 
arranged  from  the  First  to  the  Tenth  Year. 

The  Volume  is  interleaved  for  the  convenience  of 
notes — is  thoroughly  indexed  for  quick  reference  and  is 
bound  in  dark-blue  cloth  with  gilt  lettering. 

The  price  is  extremely  moderate — Only  $i  .00,  or  $2. 25  with 
new  or  renewal  subscription  to  Clinical  Medicine,  postpaid; 
after  Jan.  ist,  '08,  combination  price,  $2.75. 

Yon  MAY  EXAMINE  THE  BOOK  WITHOUT  BUYING  IT. 
OUR  OFFER:  Send  us  one  dollar — receive  the  look — look  it 
over  and  if  you  cannot  see  that  it  will  increase  your  practice 
return  it  the  same  day  and  receive  your  money  back  imme- 
diately. Address 


THE  CLINIC  PUBLISHING  CO. 

RAVENSWOOD  STATION         ...         CHICAGO 


The  American  Journal  if 
Clinical  Medicine 


"CLINICAL  MEDICINE"  gives  to  its  readers  all  that 
is  best  in  medicine  in  its  broadest  sense  (remedial, 
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It  offers  for  therapeutic  nihilism  —  dead,  blank, 
black  pessimism,  an  active,  wholesome,  optimistic 
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that  gives  results  never  before  obtained  by  the  physician. 

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"THE  AMERICAN  JOURNAL  OF  CLINICAL  MEDI- 
CINE," with  its  various  departments  of  Medicine, 
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Single  Copies,  15  Cents 
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Surgical  Therapeutics 

By 

Emory  Lanphear,  M.  D.,  LL.  D. 
St.  Louis,  Mo. 

This  4oo-page  book  covers  a  field  which  is 
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books. It  consists  of  the  detailed  surgical  facts 
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It  tells  how  to  treat  successfully  such  common 
ailments  as  piles,  rectal  fistula,  felons,  chilblains, 
varicocele,  boils,  and  carbuncles — both  surgically 
and  non-surgically,  with  special  attention  to  non- 
operative  methods.  There  are  hints  concerning  the 
management  of  fractures  and  dislocations;  concern- 
ing the  applications  of  bandages,  dressings,  and 
compresses;  concerning  the  preparation  of  patients 
for  operation  and  the  postoperative  treatment; 
concerning  the  medicinal  treatment  of  the  surgical 
diseases,  much  attention  being  given  to  this  neglected 
field.  In  a  word,  the  book  is  filled  with  the  most 
carefully  boiled-down  and  concise  helps  and  hints, 
every  one  of  which  you  can  use  in  your  work.  This 
little  book  is  not  written  for  the  surgeon  but  for  the 
general  man. 

Price  $1.00. 
Terms:  Cash  with  order,  delivery  charges  prepaid. 

The  Clinic  Publishing  Company 

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CHICAGO 


UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


A     000346160     5 


